New Patient Packet – Family Practice Clinic

Patient Information

Legal Name:

Preferred Name:

Birthdate:

Legal Sex Assigned at Birth:

Pronouns:

Gender:

Physical Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Mailing Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email:

Do you wish to have access to our online patient portal?

Cell Phone:

Home Phone:

Work Phone:

Other Demographics

Language:

Race:

Ethnicity:

Emergency Contact

First & Last Name:

Relation:

Phone Number:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Communication Preferences

How do you prefer to receive verbal communication from us? Please check which phone method is best to call and best applies to you.

Appointment Information:

Cell

Home

Work

Information from your Provider:

Cell

Home

Work

Financial Information:

Cell

Home

Work

Please type the phone number you would like us to use for Appointment Reminders:

Would you like to receive text message reminders?

Yes

No