New Patient Registration Name * First Name Last Name Preferred First Name (if different than above) Have you ever been known by another last name (ex. maiden name)? If so, what? Date of Birth * MM DD YYYY Social Security Number * Email * Phone * (###) ### #### Cell (###) ### #### Consent to Text * Yes No Consent to Automated Calls * This is used for appointment reminders. Yes No Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Race * White Black or African American American Indian or Alaska Native Asian Pacific Islander or Native Hawaiian Other Sexual Orientation * Straight or heterosexual Lesbian, gay, or homosexual Bisexual Something else Don't know Choose not to dislose Gender Identity * Identifies as male Identifies as female Transgender Male/Female-to-Male (FTM) Transgender Female/Male-to-Female (MTF) Gender non-conforming (neither exclusively male nor female) Additional gender category /other Choose not to disclose Assigned Sex at Birth * Male Female Choose not to disclose Unknown Preferred Pronouns * He/him She/her They/them Other not listed Choose not to disclose Marital Status * Single Married Divorced Partner Separated Widowed If you have children, how many? Employer Name Employer Phone (###) ### #### Usual Occupation Usual Industry Primary Insurance * Policy Number * Group Number Policy Holder Name * Policy Holder Social Security Number (if different than above) Relationship To Policy Holder Secondary Insurance Policy Holder Name (if different than above) Policy Holder Date of Birth MM DD YYYY Policy Number Group Number Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship To Patient * Is it OK to discuss your medical care with your emergency contact? * Yes No Is there another person you would give permission for us to discuss your medical care? Next Of Kin * First Name Last Name Next Of Kin Phone * (###) ### #### Relationship To Patient * Preferred Local Pharmacy and Location * Preferred Mail-in Pharmacy Preferred Inland Imaging Location Medications * Please list all medications or supplements and include dose and instructions. Please list any medical providers past or present: * How did you hear about Jessica? * Date of your last Annual Wellness Exam, if known. Name of provider for last Annual Wellness Exam. Please list any prior surgeries