TRAYNHAM MEDICAL

New patient registration

Please read the complete original form and policies (PDF) before signing. Required fields are marked *. Your entries stay on this page until you submit; they are not saved in your browser.

Preview only: online submissions are not yet open. Please use the downloadable forms.

Patient information

Full patient name *Date of birth *Street address *City *State *ZIP code *Home phone Cell phone *Email address Social Security number (optional) Driver’s license and issuing state (optional) Employer Work phone Marital status Spouse name Spouse date of birth Emergency contact other than spouse *Emergency contact phone *

Insurance and preferences

Insurance company Member / policy ID Group number Subscriber name Subscriber relationship Subscriber date of birth Subscriber Social Security number (optional) Where may we leave information? Home, cell, or mail *Local pharmacy Mail-order pharmacy Durable or healthcare power of attorney / DNR: describe and name representative

Medical history

Reason for visit *Appointment date (if known) Family history: condition and blood relative. Include epilepsy, migraine, diabetes, mental illness, easy bleeding, thyroid disease, hay fever, glaucoma, stroke, hepatitis, osteoporosis, arthritis, asthma, heart disease, HIV/AIDS, cancer, alcoholism, anemia, hypertension, high cholesterol, herpes, chlamydia, gonorrhea, genital warts, or syphilis. Write “None” if none. *All medications: name, strength, and frequency (include over-the-counter medicines). Write “None” if none. *Medication, food, and other allergies. Write “None” if none. *Conditions, surgeries and years; specialists with name and phone Tobacco use: yes/no, cigarettes/dip, and frequency Alcohol use: yes/no, type, and frequency Drug use: yes/no, street/prescription/both, and frequency

Reproductive health (if applicable)

Menstrual flow: regular/irregular, pain/cramps, last cycle, days of flow and cycle length Pain during or after sex Last Pap date and normal/abnormal result Pregnancies, miscarriages, live births, and abortions Last mammogram date, normal/abnormal, and location

Consent and signatures

I have read the general consent to treat in the patient packet and voluntarily consent to treatment. *I have read and agree to the appointment and office policies in the patient packet. *Have you received the practice’s Notice of Privacy Practices? (Yes / No / Request a copy) I have read the email consent form in the packet and choose to consent to its conditions. Patient or authorized representative: type your full name as your electronic signature *If signing for the patient, state your relationship and authority Signature date *I intend my typed name to be my signature on this submission and confirm that the information is accurate. *

Review your entries before sending. Do not enter payment card details. This form does not schedule an appointment.