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New Patient Onboarding
Let's start your care journey! These forms take 15 minutes to complete. Filling out the forms online will ensure the smoothest experience and minimize errors from handwriting. We're excited to welcome you to the South Florida Food Allergy Center family!
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Patient Registration
Patient Name
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Your answer
Today's Date
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MM
/
DD
/
YYYY
Biological Sex at Birth
*
Male
Female
Age
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Address
*
Your answer
Home or Mobile Phone
*
Your answer
Email Address
*
Your answer
Emergency Contact's Name
*
Your answer
Emergency Contact's Phone
*
Your answer
Relationship to Patient
*
Your answer
Primary Physician's Name
*
Your answer
Physician's Office Address
Your answer
Physician's Office Phone
Your answer
Physician's Fax
Your answer
Pharmacy Name
*
Your answer
Pharmacy Address
Your answer
Pharmacy Phone
Your answer
Primary Insured's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Relationship to Patient
*
Your answer
Insurance Company
*
Your answer
Member ID
*
Your answer
Do You Need a Referral?
Yes
No
Clear selection
Who can we thank for telling you about us?
Your answer
Do you have their number so we can say Thank You?
Your answer
South Florida Food Allergy Center – Remember you can call, text or fax us anytime at 561-855-1999
www.SouthFloridaFoodAllergyCenter.com
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