R&S United Health Services Mobile Doctors
Patient Registration Form
Demographic Information:
First Name
Last Name
Gender
Male
Female
Other
Marital Status
Singe
Married
Widow
SSN (For Identification purposes only)
Date of Birth
Age
Physical Address
Billing Address
Phone Number
Email
Emergency Contact:
Name
Phone Number
Email
Relationship
Insurance Billing Info:
Primary Insurance:
ID/Goup Number
Address
Health History
Choose as many based on your knowledge
Alcoholism
Amputation
Anemia
Anxiety
Atrial fibrillation
Basal Cell Cancer
Bipolar
Blind
Bone Cancer
Brain Cancer
Breast Cancer
Bronchitis
Colon Cancer
Congestive Heart Failure
COPD
Deaf
Depression
Dementia
Diabetes
Difficulty Speaking
Difficulty Swallowing
Drug Addiction
Emphysema
Glaucoma
High Blood Pressure
High Cholesterol
Hear Attack
Heartburn
HIV
Insomnia
Insulin Use
Kidney Disease
Lung Cancer
Lymphedema
melanoma
Memory Loss
Neuropathy
Osteoporosis
Paralysis
Parkinson's
Poor Circulation
Prostate Cancer
Psoriasis
Rheumatoid Arthritis
Schizophrenia
Seizures
Shingles
Skin Ulcers
Squamous Cell Cancer
Stomach Ulcers
Strokes
Throat Cancer
Thyroid Underactive
Tobacco Use
Tremors
Trouble Hearing
Unsteady Walk
Urine Cancer
Wheelchair Dependent
Other
Other History
Prescription Medication List
Please attach additional page if needed
1
Medication
Dose
2
Medication
Dose
3
Medication
Dose
4
Medication
Dose
Attach other info that may help to better treat patient
Select a File
Allergies:
Please list all allergies and reactions
Previous Provider List
Please list the names of any previous providers where we should request your medical records. (Provider and Phone Number)
Please list provider and Phone number
Attach other info that may help to better treat patient
Select a File
Your Signature
*
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