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Established Patient Paperwork
If you've already been seen by one of our providers in the last 365 days at the Fosnight Center, please fill out this form when seeing a new provider for the first time.
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* Indicates required question
Name ( first and last)
*
Your answer
Legal Name (if different from above)
Your answer
Date of Birth (mm/dd/yyyy)
*
Your answer
My pronouns are: (she/her, he/him, they/them, etc)
*
Your answer
Current mailing address: (please include zip code)
*
Your answer
Any changes in your health insurance policy? (if yes, please provider insurance company and subscriber ID number
*
Your answer
What type of appointment are you here for today?
*
Urology
Gynecology
Sexual Medicine
Physical Therapy
Mental Health
Integrative Medicine
Required
Reason for this visit at the Fosnight Center
*
Your answer
Can you relate this concern with any event or change in your life?
*
Your answer
Are you currently taking any supplements or prescription medications? (if answer yes, please list medications)
*
Your answer
Any changes in your health history since your last visit with Fosnight Center? (please explain if answer yes)
*
Your answer
Any additional information you would like to provide regarding this new patient appointment?
Your answer
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