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New Patient Paperwork - Liberty Healthcare Partners
Please select which provider you wish to establish care with:
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PATIENT INFORMATION
First Name:
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Middle Initial:
Last Name:
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Birth Date:
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Age:
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Gender (at birth):
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Social Security:
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Email:
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Address:
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City:
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State:
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Zipcode:
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Cell Phone:
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Home Phone:
Marital Status:
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Race:
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African American
Asian/Pacific Islander
Hispanic/Latino
Caucasian
Other: Specify
Language:
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Emergency Contact Person:
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Emergency Contact Number:
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Relationship
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INSURANCE INFORMATION
Primary Insurance Carrier:
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Member/Subscriber ID #:
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Secondary Insurance Carrier:
Member/Subscriber ID #:
Person responsible for payment:
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(If other than patient)
Relationship to patient:
Responsible Party Address (if different from patient):
How did you hear about our office:
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Previous PCP:
Previous PCP Phone:
Preferred Pharmacy:
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Preferred Pharmacy Address:
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Mail Order Pharmacy:
Medical History -
List any problems/medical conditions you currently take medications for.
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if none, please write
"NONE"
Surgical/Hospitalization History -
List any surgeries/hospitalizations with Dates.
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If none, please write “NONE”
Allergies -
List medications and/or materials/foods you are allergic to and reaction type.
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If none, please write “NONE”
Current Medications -
List all (prescribed and/or non-prescription) medications, and the dose/frequency.
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If none, please write “NONE”
Family History -
List ANY family history of medical problems.
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If none, please write “NONE”
Social History
Tobacco/Nicotine use:
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Select all that apply
Are you routinely exposed to second-hand smoke?
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Alcohol use:
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Preventative Health Testing - List Month/Year and Result Options
If none, please write “NONE”
Mammogram:
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Pap Smear:
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Colonoscopy/ColoGuard:
Bone Density/Dexa Scan:
Eye exam:
Prostate Exam:
Consents
Select a policy to read:
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I have read and understand the policies listed above. I understand that should I have any questions, I will be directed to a staff member who can address my concerns.
Patient Signature:
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Signature
Date:
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PLEASE FILL OUT THE BELOW SECTION FOR OUR OFFICE TO REQUEST MEDICAL RECORDS FROM PREVIOUS PROVIDER/SPECIALIST OFFICE:
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