Online Patient Registration and Information Form

Dr. Lloyd Brenden Nov 21, 2024

PATIENT INFORMATION

By completing the following form we can reduce paperwork and save you time filling out forms in our office before seeing Dr Brenden.

If you prefer to download, print and complete our form by hand, you can access it here: Printable Patient Registration Form (3 pages).

Additional fields will appear on the form when previous answers indicate that additional information is needed.

You can copy and paste information such as your medications list, medical history, and pathology reports from other doctors into the text fields provided. If you need more space or have supporting documents or pictures you may bring them with you when you come to your appointment with Dr. Brenden or upload them in the space provided near the bottom of this form.

You will need to bring your insurance card(s) and photo ID to your appointment for us to copy and scan into your e-chart.

Once completed and submitted, this form will be stored securely in a HIPAA compliant environment

First Name

Middle

Last Name

Date of Birth

Gender

Male Female

Local billing address

Alternate billing address

Preferred Phone Number with Area Code

Other Phone Number

Primary Care Physician Name

Primary Care Physician Phone Number

Pharmacy Name

Pharmacy Phone

Pharmacy Cross Streets

Insurance Coverage:

Self Pay Covered by Insurance Traditional Medicare Medicare Replacement Plan

Who can we give your protected information to?

No One

Permission to leave voicemail

Yes No

Do we have your permission to leave voicemail messages on your phone regarding test results and appointments?

Allergies

I have no known drug allergies I have had allergic reactions to the medications or substances listed below

Medications

Please provide us with a complete list of your current medications, . Please include over-the-counter, herbals, vitamins and other supplements. You may upload your medications near the end of this form rather than entering them here if you prefer.

Name of Medication

Dosage

Frequency

Route

How Long

For What

Marital Status:

Single Married Divorced Widowed

Living Arrangement

Live alone Live with spouse/partner Parent(s) Child/Children Friends Other

Number of living children

Spend time in the sun for work or pleasure?

Yes No

Employment Status

Currently employed Currently unemployed Retired

Present Occupation

Former Occupation

Purpose of Visit?

Additional details about the history of what’s been going on, for how long and what’s been tried. (optional)

Attachments

Attach additional information here. You may upload lists and other documents such as your medications list, medical history, pathology reports from other doctors, photos of a skin lesion or rash, etc. if you wish to do so. File types accepted jpg, png, txt, doc, docx and pdf.

Please remember to bring your insurance card(s) and photo ID to your appointment for us to copy and scan into your e-chart.

Online Patient Registration and Information Form

PATIENT INFORMATION

Who can we give your protected information to?

Medications

Medical History

Past Medical Conditions

Infections

Surgeries

Attachments