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- Forms
  - Patient Registration
Contact Us

Make an Appointment

866 603 7505

866 603 7505

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Home
About Us
Our Services
Patient Resources
- Insurance Acceptance
- Forms
  - Patient Registration
Contact Us

Home
About Us
Our Services
Patient Resources
- Insurance Acceptance
- Forms
  - Patient Registration
Contact Us

Make an Appointment

Make An Appointment

Book Your Appointment For Better Health

Patient Name

Date of Birth

Date Completed

1. General Health

How would you rate your overall health?

Do you have a primary care provider?

Do you have any current medical concerns?

1. Medical Condition

Have you ever been diagnosed with (check all that apply):

Cancer Type

other

2. Surgeries & Hospitalizations

List any surgeries and/or hospital stays:

2. Surgeries & Hospitalizations

Current Medications (include over-the-counter, vitamins, supplements):

Allergies

Family Medical History (Indicate which relatives had the condition)

Diabetes

Heart Disease

High Blood Pressure:

Cancer (Type)

Stroke

Other

Do you smoke?

Do you drink alcohol?

Do you use recreational drugs?

Exercise

Diet

7. Women’s Health (if applicable)

Age at first period

Are periods regular?

Pregnancies

Live Births

Miscarriages

Date of last period

Date of last Pap smea

Date of last Mammogram

8. Additional Notes / Concerns

Nutrition & Eating Habits

How many servings of fruits/vegetables do you eat daily?

How often do you eat fast food or processed foods?

Do you follow a special diet?

Physical Activity

How often do you exercise?

What type of exercise do you usually do?

How many hours a day do you spend sitting (work, screen time, etc.)?

Sleep

On average, how many hours of sleep do you get per night?

Do you have trouble falling or staying asleep?

Stress & Mental Wellbeing

How often do you feel stressed?

Do you have a support system (friends, family, community)?

Have you ever been diagnosed with a mental health condition?

Signature

I confirm that the information provided above is true to the best of my knowledge.

Signature:

Date

If Legal Representative, Relationship to Patient:

Patient Name

Date of Birth

Appointment Hours

Date Completed

Insurance

1. General Health

How would you rate your overall health?

Do you have a primary care provider?

Do you have any current medical concerns?

1. Medical Condition

Have you ever been diagnosed with (check all that apply):

Cancer Type

other

2. Surgeries & Hospitalizations

List any surgeries and/or hospital stays:

2. Surgeries & Hospitalizations

Current Medications (include over-the-counter, vitamins, supplements):

Allergies

Family Medical History (Indicate which relatives had the condition)

Diabetes

Heart Disease

High Blood Pressure:

Cancer (Type)

Stroke

Other

Do you smoke?

Do you drink alcohol?

Do you use recreational drugs?

Exercise

Diet

7. Women’s Health (if applicable)

Age at first period

Are periods regular?

Pregnancies

Live Births

Miscarriages

Date of last period

Date of last Pap smea

Date of last Mammogram

8. Additional Notes / Concerns

Nutrition & Eating Habits

How many servings of fruits/vegetables do you eat daily?

How often do you eat fast food or processed foods?

Do you follow a special diet?

Physical Activity

How often do you exercise?

What type of exercise do you usually do?

How many hours a day do you spend sitting (work, screen time, etc.)?

Sleep

On average, how many hours of sleep do you get per night?

Do you have trouble falling or staying asleep?

Stress & Mental Wellbeing

How often do you feel stressed?

Do you have a support system (friends, family, community)?

Have you ever been diagnosed with a mental health condition?

Signature

I confirm that the information provided above is true to the best of my knowledge.

Signature:

Date

If Legal Representative, Relationship to Patient:

I agreed with the

Terms and conditions Privacy policy Patient Rights

Appointment Hours.

Office Hours

Monday - 8:00am – 7:00pm
Tuesday - 8:00am – 7:00pm
Wednesday - 8:00am – 7:00pm
Thursday - 8:00am – 7:00pm
Friday – 8:30am – 6:00pm
Saturday – 9:00am – 1:00pm
Sunday Closed

Patient Information

Full Name

Date of Birth

Gender

Male Female Other Prefer not to say

Marital Status

Single Married Divorced Widowed

Social Security Number (if applicable)

Address

City / State / Zip

Phone Number (Home)

Phone Number (Mobile)

Email Address

Preferred Contact Method

Phone Email Text

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Providing compassionate, expert care to ensure the well-being of you and your family at every stage of life.

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schedule hours

Monday to Thursday: 8:00 AM – 7:00 PM
Friday: 8:30 AM – 6:00 PM
Saturday: 9:00 AM – 1:00 PM
Sunday: Closed

Our address

2964 NORTH STATE RD 7 SUITE 310, MARGATE FL 33063

Terms and conditions
Privacy policy
Patient Rights

First Name

Last Name

Email

Phone

Services

Date

Time