P: (386) 957-1854

F: (386) 878-4967

502 Palmetto Street

New Smyrna Beach, FL 32168
 

©2016 BY WWW.NEWSMYRNAWELLNESS.COM 

New Patient Form
My Phone Preference is:
New Smyrna Wellness Center may leave a message on your answering machine or voicemail regarding appointment reminders?
Current Marital Status:
Please click here and skip insuance information if patient is self-pay:

Complete the following if you have a Secondary Insurance

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

Family History

Are you adopted?
Mother is
Father is

Social History

Smoking/Tobacco Use
Alcohol Consumption
With whom do you live? (Check all that apply)
Do you have any implantable devices?

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.