New Patient Registration
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
New Patient Registration
* Required Information
Name
Dob
Age
*
Sex
Male
Female
Other
*
SSN
*
Marital status
Married
Single
Divorced
Widowed
*
Race
*
Ethnic background
*
Address
*
Phone
Home
Cell
Work
Home
Cell
Work
Home
Cell
Work
*
Email
*
Referred by
DME Company
Self-Referral
Existing SMI Patient
Existing YMD Patient
Friend or Family Member
INSPIRE Referral
Insurance
Physician Fax Referral
Radio/TV/Print Ads
Seminar/Health Fair
SMI Office Sign
Google
Facebook
Social Media
DOT
VA Patient
SMI Website
Yellow Pages
*
Have you been referred by a M.D.?
Yes
No
Phone number
Primary Care M.D.
Phone number
Emergency contact information
*
Name
*
Relationship
*
Address
*
Phone number
2nd Phone
Pharmacy name
Phone number
Address
Please list any medications you are currently taking.
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
Medication #11
Medication #12
Medication #13
Medication #14
Medication #15
I have more medications to report
*
Allergies
If none, type "none".
Appointment of personal representative to receive protected health information
You may rely upon your spouse, relatives or friends from time to time to understand your treatment options, visit your physicians, acquire prescriptions, get test results, and otherwise be involved in your medical care. However, federal law does not allow us to disclose any of this information to these people unless you give us authorization to do so, except in an emergency situation. I wish to be contacted by Sleep Management Institute in the following manner (click all that apply)
"Leave message" indicates on answering machine or with the person that answers the phone.
*
Home
Yes
No
Leave message which includes clinical information
Leave message with call back number only
Do not leave message
*
Cell
Yes
No
Leave message which includes clinical information
Leave message with call back number only
Do not leave message
*
Work
Yes
No
Leave message which includes clinical information
Leave message with call back number only
Do not leave message
*
Written communication
Yes
No
Mail to home address
Mail to work address
Do not send me mail
*
Email *not a secure form of communication
Yes
No
Email can include clinical information
Email a call back number only
Do not email
*
Text *not a secure form of communication
Yes
No
Text can include clinical information
Text a call back number only
Do not text
Authorization of Medical Information
The listed names are those to which I give Sleep Management Institute the authorization to discuss minimum necessary medical information
Person #1
Person #2
Person #3
I may revoke this appointment at any time. My revocation will not affect any actions that have been already taken in reliance on my original appointment.
Name
Date
*
Signature
Please sign in the box above
Reset Signature
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