New Patient Registration

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Middle initial

Last Name

Date of Birth

Number

Street

Mailing number

Mailing street if different, or P O Box.

City

State

Zip

Home phone number

Cell phone number

Email address

Emergency Contact Information

First name

Last name

How is this person related to you?

Home phone number

Cell phone number

Medical History

Please list your medical problems in this box.

Please list the medications you are taking, the dose, and how often you take the medication.

Please note: I do not prescribe the following medications on a long term basis for new patients: Oxycodone, hydrocodone, alprazolam lorazepam, adderall, amphetamine, methylphenidate, focalin, daytrana

Please list any medications that you are allergic to, and the reaction you had.

Do you smoke?

Yes.

No.

Cigarettes per day.

Do you drink alcohol?

Yes

If yes, how much?

Are there any health concerns in your family? Father:

Mother:

Siblings:

Other relatives:

Insurance name

Insurance number

Signature

Signed

Type your full name

Today's date

Your information will be encrypted.

New Patient Registration

Emergency Assistance

Client Information

Emergency Contact Information

Medical History

Signature

Emergency Assistance

Robert B Rovner, MD

Family Doctor