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Elizondo Medical Group New Patient Screening
Patient Information
Last Name
(Required)
First Name
(Required)
Date of Birth:
(Required)
Home Phone:
Work/Cell:
Preferred Provider:
Age:
Patient Information (We are not taking any New Patient's with any Medicaid plans)
Home Address:
(Required)
City/State/Zip:
(Required)
SS#
(Required)
Sex:
(Required)
Male
Female
Transgender
Previous Dr.
E-mail Address: (for Patient Portal)
(Required)
Preferred Language:(mark if Spanish Only and put note on reason to inform MA/Provider)
(Required)
English
Spanish
Sign Language
Other
Medical Insurance
Primary Insurance Name:
Policy Number:
Group #:
Responsible Party:
Self
Spouse
If Spouse is insured, name of Spouse:
Secondary Insurance Name:
Policy Number:
Group #:
Responsible Party:
Self
Spouse
**If patient answered YES to any of the below questions, DO NOT SCHEDULE APPOINTMENT, approval will be required from Office Administrator**
**If patient answered NO to the above questions, inform patient if a medication is not listed, we may not be able to refill this medication at time of appointment and they will be referred to a specialist for treatment of that condition. All current medications will be reviewed at the time of the visit and the treating provider may discuss current and future medication regimens.**
Chronic Conditions
Are you currently taking any medication for Pain?
(Required)
Yes
No
**Rx name
mg
qty per day
Are you currently taking any medication for Anxiety?
(Required)
Yes
No
**Rx name
mg
qty per day
Are you currently taking any medication for Depression?
(Required)
Yes
No
**Rx name
mg
qty per day
Are you currently taking any medication for Attention Deficit Disorder?
(Required)
Yes
No
**Rx name
mg
qty per day
Are you currently taking any medication for Drug Withdrawal?
(Required)
Yes
No
**Rx name
mg
qty per day
Appointment Date / Time:
Provider Name:
Receptionist name:
Date:
MM slash DD slash YYYY
Patient Signature:
Date:
MM slash DD slash YYYY
NOTE: REMIND PATIENT TO BRING ALL MEDICATION BOTTLES, PICTURE ID OR DRIVERS LICENSE, INSURANCE CARDS ON DAY OF APPOINTMENT, AND IF NEW PATIENT PACKET EMAILED, TO RETURN BEFORE APPOINTMENT DATE.