NEW PATIENT Name * First Name Last Name Legal Sex * Male Female Date of Birth * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Mobile Phone * (###) ### #### Consent to receive automated calls about appointment updates * Yes No Consent to receive automated texts about appointment updates * Yes No Language English Other Race American Indian Asian Asian Indian Black or African American European Filipino Japanese Korean Native Hawiian or Other Pacific Islander White Ethnicity Central American Cuban Dominican Hispanic or Latino Latin American Mexican Not Hispanic or Latino Puerto Rican South American Spaniard Marital Status Married Single Divorced Seperated Widowed Partner How did you hear about us? * * I authorize this clinic to download my medication history from pharmacy benefit managers (PBMs) Emergency Contact Emergency Contact Relationship Spouse Parent Child Sibling Friend Cousin Guardian Other Emergency Contact Phone Number Insurance * If no insurance policy is provided, you will be assigned cash pay status initially Cash Pay Medicare Medicaid Aetna Cigna BCBS of Nevada BCBS of Nevada Medicare Tricare United Healthcare Other Member ID Policy Number HMO POS PPO Other Preferred Pharmacy Name * Pharmacy Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pharmacy Phone * (###) ### #### Message Thank you!We will reach out to discussestablishing you as our newestpatient.