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


    Please type allergic reactions and other medication allergies?


    Please type names of other medications you take

    Smoking history

    Alcohol history

    Did you get the Flu Vaccination?

    Height Ft' Inches" (5'9")


    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!