702-948-9480

New Patient Registration Form

Fields required*


Please complete form and submit


If you prefer or choose not to use online medical forms, you can print these forms and fax them to 702-948-9488 or bring them with you to the office. Thank you.

Select your physician
First name - last name and relationship
Emergency contact phone
Pharmacy - Major Cross Streets - Zip Code

Medical History



Allergies


Please type allergic reactions and other medication allergies?

Medications


Please type names of other medications you take
Smoking history
Alcohol history
Did you get the Flu Vaccination?
Height Ft' Inches" (5'9")
(lbs)

Ongoing Medical Problems



Surgical History



Family History



Systems Review


I acknowledge that this form may not be secure. Any health information I choose to share on this form is at my own risk.


Please bring pertinent records, medication, supporting laboratory, and radiology studies with you. Please note that some insurances require prior authorization- Please contact your primary provider to obtain and confirm you have the appropriate authorization. Without authorization you may not be able to see the physician. Thank you for understanding. We will contact you within 24-48 hrs to schedule an appointment.



Thank you and have a great day!