Apollo & Carolina Primary Care - New Patient Forms

Page 1 of 4 - Patient Registration

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Apollo Urgent Care / Carolina Primary Care & Women's Health

101 Lattner Court, Ste 100
Morrisville NC 27560
Phone: (919) 297-0348 Fax: (919) 297-0349
Today's Date Today's Date * / MM / DD YYYY
Patient Information
Name Name * First Middle Last
Date of Birth Date of Birth * / MM / DD YYYY
Sex *

Sex Male Female
SSN
Must be 11 characters. Currently Entered: 0 characters.
Format: XXX-XX-XXXX
Parent or Guardian (if minor patient) Parent or Guardian (if minor patient) First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone * - ### - ### ####
Mobile Phone Mobile Phone - ### - ### ####
Email
Preferred Language
Ethnicity

Ethnicity Hispanic or Latino Non-Hispanic or Latino
Race

Race Native American Caucasian Hispanic or Latino African American Asian
How did you hear about us?

How did you hear about us? Web search Internet Ad Magazine or Paper Friend, Family or Colleague Doctor or Healthcare professional
Emergency Contact Name
Relationship
Phone Phone - ### - ### ####
Insurance Information
Primary Insurance
ID Number
Group#
Policy Holder Information *

Policy Holder Information Self (patient is the policy holder) Other (patient is NOT the policy holder)
Policy Holder Name Policy Holder Name * First Last
Date of Birth Date of Birth * / MM / DD YYYY
Sex *

Sex Male Female
SSN
Must be 11 characters. Currently Entered: 0 characters.
Format XXX-XX-XXXX
Relationship to Patient

Relationship to Patient Spouse Parent Guardian Other
Do you have secondary insurance?

Do you have secondary insurance? Yes No
Secondary Insurance
ID Number
Group#
Medications

Please list any medications you are currently taking. Include the dose if you know it.
Are you taking any medications currently? *

Are you taking any medications currently? Yes No
Name of medication (1)
Dose
Name of medication (2)
Dose
Name of medication (3)
Dose
Name of medication (4)
Dose
Name of medication (5)
Dose
Name of medication (6)
Dose
Name of medication (7)
Dose
Name of medication (8)
Dose
Name of medication (9)
Dose
Allergies

List allergies to any medications you have below.
Are you allergic to any medications, that you know of? *

Are you allergic to any medications, that you know of? Yes No
Allergic to medication (1)
Reaction
Allergic to medication (2)
Reaction
Allergic to medication (3)
Reaction
Preferred Pharmacy

Please list your preferred pharmacy below.
**Please make a note of which medications should go to each pharmacy if you use multiple pharmacies.
Pharmacy Name (1)
Address
Pharmacy Name (2)
Address
Past Medical History

Please select either Yes or No to each of the medical condition
	Yes	No
ADD/ADHD	ADD/ADHDYes	ADD/ADHDNo
Anemia	AnemiaYes	AnemiaNo
Anxiety	AnxietyYes	AnxietyNo
Heart Disease	Heart DiseaseYes	Heart DiseaseNo
Arthritis	ArthritisYes	ArthritisNo
Asthma	AsthmaYes	AsthmaNo
Cataracts	CataractsYes	CataractsNo
Cancer	CancerYes	CancerNo
CHF	CHFYes	CHFNo
COPD	COPDYes	COPDNo
Depression	DepressionYes	DepressionNo
Diabetes	DiabetesYes	DiabetesNo
Dizziness	DizzinessYes	DizzinessNo
Eczema	EczemaYes	EczemaNo
Emphysema	EmphysemaYes	EmphysemaNo
Epilepsy	EpilepsyYes	EpilepsyNo
Gout	GoutYes	GoutNo
Heart Attack	Heart AttackYes	Heart AttackNo
High blood pressure	High blood pressureYes	High blood pressureNo
High cholesterol	High cholesterolYes	High cholesterolNo
HIV	HIVYes	HIVNo
Hormone imbalance	Hormone imbalanceYes	Hormone imbalanceNo
Kidney Disease	Kidney DiseaseYes	Kidney DiseaseNo
Liver Disease	Liver DiseaseYes	Liver DiseaseNo
Migraines	MigrainesYes	MigrainesNo
Pace maker placement	Pace maker placementYes	Pace maker placementNo
Stroke	StrokeYes	StrokeNo
Thyroid disease	Thyroid diseaseYes	Thyroid diseaseNo
Venereal Disease	Venereal DiseaseYes	Venereal DiseaseNo

Please list any other medical condition that were not listed above
Past Surgical History
Please list all surgeries and the year they were performed in the space provided below.
Family History of Significant Disease
Please list any family history of significant disease and your relationship to the family member in the space provided below.
Previous Medical Care
Previous primary care physician
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
Date of last check-up

Apollo & Carolina Primary Care - New Patient Forms

Page 1 of 4 - Patient Registration

Apollo Urgent Care / Carolina Primary Care & Women's Health

Patient Information

Insurance Information

Medications

Allergies

Preferred Pharmacy

Past Medical History

Past Surgical History

Family History of Significant Disease

Previous Medical Care