Patient Forms

New Patient Information

First and Last Name*

Date of Birth*

Current Age*

Partner Status*

Race*

Gender

Select valuemalefemaleother

Preferred pronouns

Select valuehe/himshe/herthey/themother

Current medications, doses, and when each is due to run out*

Mailing address*

City*

State

Zip*

Cell Phone*

Home Phone*

Is it OK to leave a message?*

Select valueYesNo

Email address (preferred method of communication)*

Emergency Contact Relationship*

Emergency Contact Cell Phone*

Emergency Contact Email Address*

Emergency Contact Name*

Pharmacy name, location, and phone number*

Name of lab you use for bloodwork*

Name of your medical doctor*

Type of Doctor*

Select valueInternal MedicineFamily Medicine

Names of other medical specialists you see*

Name of your therapist (if you have one)*

Who referred you to WPH?*

PLEASE ANSWER AND EXPLAIN IF NEEDED

Active suicidal thoughts

Yes

No

If you have suicidal thoughts, please explain

Active psychotic thoughts

Yes

No

If you have psychotic thoughts, please explain

Active substance abuse

Yes

No

Please explain substance abuse issues

Active legal issues

Yes

No

Please explain legal issues

reCAPTCHA

SubmitReset