INTERNAL MEDICINE ASSOCIATES OF DALLAS

Select one:

Joseph Rothstein, MD Pratik Kapadia, MD Nazish Islahi,MD

Today’s Date:

Chart#:

Name: (Last)

(First):

(Middle):

Address: (Street#,Name)

(City):

(State):

(Zip):

Home Phone:

Cell Phone:

Work Phone:

Date of Birth:

Sex:

Female Male Unknown Transgender

Marital Status:

Divorced Married Partner Single Widowed Legally Separated

SSN#:

Employer Name:

Employed:

Full time Part time Not employed Self employed Retired On Active Military Reserved for assignment

Student status:

Full time Part time Not a student

Emergency contact:

Are they a current patient?

Yes No

Name: (Last)

(First):

(Middle):

Address:(Street#,Name)

(City):

(State):

(Zip):

Relationship:

Phone#:(Home/Cell)

(Work):

**Insurance policy holder information: (if self-then skip to additional information)

Are they a current patient?

Yes No

Name: (Last)

(First):

(Middle):

Relationship:

Date of Birth:

SSN:

Phone#:

Sex:

Male Female

Address:(Street#,Name)

(City):

(State):

(Zip):

Employer name:

Employer address:

Employer Phone:

**Additional information

Sign up for patient portal?

Yes – please fill out the consent No - please check reason no email decline

Which number should we use to confirm appointments and contact you with results?

Home Cell Work

Ok to leave which kind of message on the phone designated above?

Brief Detailed

Race:

Ethnicity:

Hispanic/Latino Not Hispanic/Latino

Language:

English Spanish

Pharmacy Name:

Phone#:

Referred by:

INTERNAL MEDICINE ASSOCIATES OF DALLAS

PLEASE PRESENT YOUR DRIVERS LICENSE/ID AND INSURANCE CARDS TO THE CHECK IN DESK