P: (386) 957-1854

F: (386) 878-4967

502 Palmetto Street

New Smyrna Beach, FL 32168

New Patient Form

First Name

Middle Name

Date of Birth (mm/dd/yyyy)

Preferred Name

Last Name

Gender

Home Phone

Cell Phone

Work Phone

Email

My Phone Preference is:

Home Phone

Cell Phone

Work Phone

No Preference

New Smyrna Wellness Center may leave a message on your answering machine or voicemail regarding appointment reminders?

Yes

No

Home Street Address

City

State

Zip Code

Social Security Number

Name of Spouse or Significant Other

Current Marital Status:

Single

In a relationship

Engaged

Married

Separated

Divorced

Widowed

Please click here and skip insuance information if patient is self-pay:

Self-pay/Cash

Primary Insurance Plan Name

Group Number

Insurance Policy Number

Primary Insurance Company Phone Number

Complete the following if you have a Secondary Insurance

Secondary Insurance Plan Name

Group Number

Insurance Policy Number

Secondary Insurance Company Phone Number

Employer name (if Insurance is through an employer)

Employer Phone Number

Answer the following section if your are not the policy holder of your health insurance

Name

Relationship of Subscriber to Patient

Street Address

State

Date of Birth (if other than Self)

Phone Number

City

Zip Code

Please list your Primary Care Doctor and other Specialists

Name of Emergency Contact

Contact's Relationship to Patient

Phone Number

Your preferred local pharmacy

Your preferred mail order pharmacy

How did you hear about New Smyrna Wellness Center?

List all Allergies (Please include Allergen, Severity, Reaction, Onset)

List all Medications, Supplements, and Vitamins (Name, Dose, Frequency, Reason)

Past Medical History

Past Surgical History

Family History

Are you adopted?

Yes

No

Mother is

Living

Deceased

Unknown

Mother's health issues and/or cause of death:

Father is

Living

Deceased

Unknown

Father's health issues and/or cause of death:

Any other significant family history of genetic diseases, autoimmune disorders, cancer, etc.?

Social History

Smoking/Tobacco Use

Never Smoker

Current Smoker

Former Smoker

Current/Former Smokers

Former smokers, what year did you quit smoking?

Alcohol Consumption

None

Occasionally

1-2 drinks per week

3-5 per week

6+ per week

If you consume alcohol daily, how much do you drink?

With whom do you live? (Check all that apply)

Alone

Spouse

Significant Other

Parent(s)

Friend(s)

Roommate(s)

Child(ren)

Other

Do you have any implantable devices?

Yes

No

Please list your implantable devices.

What are your main goals for your visit to our clinic?

Are there any other symptoms that you would like to make the Health Care Team aware of?

Please note that, in most instances, we will need your prior medical records before your visit. Please have your doctor's office send records or bring the records to our office prior to your visit.

We also encourage you to read the pdf version of the New Patient Paperwork, which includes New Smyrna Wellness Center's Policy and Procedures.

Thanks for submitting!

(386) 957-1854

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