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Elizondo Medical Group New Patient Inquiry
Patient Information
Last Name
(Required)
First Name
(Required)
Date of Birth:
(Required)
Home Phone:
Work/Cell:
Preferred Provider:
Age:
Patient Information (We are not taking any New Patient's with any Medicaid plans)
Home Address:
(Required)
City/State/Zip:
(Required)
SS#
(Required)
Sex:
(Required)
Male
Female
Transgender
Previous Dr.
E-mail Address: (for Patient Portal)
(Required)
Preferred Language:(mark if Spanish Only and put note on reason to inform MA/Provider)
(Required)
English
Spanish
Sign Language
Other
Medical Insurance
Primary Insurance Name:
(Required)
Policy Number:
(Required)
Group #:
Responsible Party:
Self
Spouse
If Spouse is insured, name of Spouse:
Secondary Insurance Name:
Policy Number:
Group #:
Responsible Party:
Self
Spouse
Chronic Conditions
Are you currently taking any medication for Pain?
(Required)
Yes
No
If Yes, pain location?
(Required)
**Rx name, if answered yes
(Required)
mg
(Required)
qty per day
(Required)
Are you currently taking any medication for Anxiety?
(Required)
Yes
No
**Rx name, if answered yes
(Required)
mg
(Required)
qty per day
(Required)
Are you currently taking any medication for Depression?
(Required)
Yes
No
**Rx name if answered yes
(Required)
mg
(Required)
qty per day
(Required)
Are you currently taking any medication for Attention Deficit Disorder?
(Required)
Yes
No
**Rx name if answered yes
(Required)
mg
(Required)
qty per day
(Required)
Are you currently taking any medication for Drug Withdrawal?
(Required)
Yes
No
**Rx name if answered yes
(Required)
mg
(Required)
qty per day
(Required)
Preferred Provider:
Patient Signature:
(Required)
Date:
MM slash DD slash YYYY
