New patient form | Mid Atlantic Rheumatology

Personal information

First Name*
Last Name*

Address line 1*
Address line 2

City*
State*
ZIP code*

Phone number (to reach you for urgent messages)*
Phone number (To reach you)
Email
Date of birth*
Emergency contact person, phone number and relationship to you*

Name of your primary care physician

First Name*
Last Name*

Referral

Who referred you to us, if not your Primary ID
Reason for your referral

Insurance

Your primary insurance MedicarePPOHMO
Primary insurance Name, ID #, group #*
Name of insured person and their date of birth

Pharmacy

Your pharmacy name, address and telephone number*
Names of medications you are on, the dose and how often you take them*
Have you been hospitalized in the last year and if so, why?*
Have you have any surgeries, if so when and why?
Do you have any of the following conditions?Rheumatoid arthritisLupusGoutFibromyalgiaHeart diseaseHypertensionDiabetes
Do you have a family history of arthritis or lupus?
List any drug allergies you have

Additional information

Are you employed?YesNoRetired
Do you drink alcohol socially? YesNo
Do you smoke cigarettes?YesNo
Marital statusMarriedSingleDivorcedPrefer not to answer

Your most recent height
Your most recent weight

Please upload any reports you would like us to review

By checking this box, I acknowledge that I have had an opportunity to read the practice privacy and financial policy. I intend to keep my scheduled appointment. If I am unable to keep my appointment, I will call the practice before my appointment time and reschedule/cancel my appointment. My failure to do so may result in me being charged a $50 no show fee.*

I agree
Signature*