New Patient Registration Form

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Please fill out the first part of this form if you would like to schedule an appointment now... Office Hours are Monday, Wednesday, Friday 11 AM to 4 PM, Tuesday 11 AM untill 6 PM.... The Medical History Part of this form is OPTIONAL. You may fill it out later. You may print this form and mail it or bring it with you if you don't want to fill it out online................................................. PART ONE- REGISTER.................

Please indicate your preferred appointment time. We shall endeavor to provide the closest time. Appointments after 4 available on Tuesday only. No Routine appointments on Thursday.

Which Month

Which Date

Which Day of the Week

At What Time

Name:

Street Address:

City,State,Zip:

Email:

Daytime or Work Phone:

Evening or Home Phone:

Date of Birth:

Social Security No:

How do you intend to pay?

Cash
Check
Insurance
Mastercard/Visa

If by Insurance:

Name of Company:

Policy Number:

Group Number (if present):

Insurance Company Phone Number:

Name of 2nd Co(if present):

PART TWO-MEDICAL HISTORY

Write your Medication allergies here. If none, state

None::

What are your

Medications:

Please list your past operations and serious

illnesses::

Are there diseases in your

Family::

Please describe all your current medical

concerns::

Preventive Care: When was your last:

Physical Exam:

Chest XRay:

EKG:

Eye Exam:

Mammogram:

Pap Smear:

Prostate/Rectal Exam:

Pneumococcal Shot:

Tetnus Booster:

Do you Smoke?

No
Yes

How much?:

Do you use Alcohol?

No
Yes

How much ?:

If you would like us to obtain your past record, please write your previous Doctor's name & address.

here::

Please list any comment here:

Directions to Office

..
Preventive Care Page

...
Return to Homepage

Press Submit Button only once. You will not see a confirmaiton. We will contact you by email and by phone to confirm your appointment. Thank you for choosing Dr. Schor.