New Patient Information Form
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Step
1
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PATIENT DETAILS
Patient Name
*
First
Last
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Date of Birth
*
Sex
*
Male
Female
Unspecified
Email
We will never rent or sell your email address - we value your privacy.
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Cell Phone Number
*
Home Phone Number
Mailing Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Marital Status
*
Single
Married
Divorced
Widowed
Your Employer Name
Leave empty if not currently employed.
Reason For Appointment
*
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PATIENT DEMOGRAPHIC
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Language
*
Race
*
African American
American Indian/Alaska Native
Asian
White
Mixed Race
Other
Refuse to Report
Marital Status
*
Married
Single
Divorced
Ethnicity
*
Hispanic
Not Hispanic
Refuse to Report
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EMERGENCY CONTACT INFORMATION
Emergency Contact's Name
*
First
Last
Contact Number
*
Relation to Patient
*
May We Send Them Information?
No
Yes
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MEDICAL INSURANCE INFORMATION
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Insurance Company
ID Number
Policy Holder Name
First
Last
Relationship to Patient
Policy Holder's Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Policy Holder Employer
Policy Holder's Birth Date
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PHARMACY INFORMATION
Recommended Pharmacy: Walmart, Germantown MD
Yes
No
I would like to use ICM Cares recommended pharmacy (Walmart, Germantown). If not, please provide your pharmacy information below.
Walmart Germantown Address: 20910 Frederick Rd, Germantown, MD 20876
Preferred Pharmacy
*
Address of Pharmacy
Prescription Consent
*
Yes
No
I give ICM Cares Clinic permission to write prescriptions on my behalf.
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CONSENT FOR SMS COMMUNICATION
ICM Cares Clinic may message you with information regarding your health visit or prescription updates.
SMS Consent
I voluntarily consent to receive SMS (TEXT) communication from ICM Cares Clinic
*
Yes
No
Please choose an option.
CONSENT FOR TREATMENT
I voluntarily consent to any and all health care treatment and diagnostic procedures provided by ICM Cares Clinic and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at ICM Cares Clinic.
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Patient or Authotized Person's Name
*
First
Last
Date
*
Checkboxes
First Choice
Second Choice
Third Choice
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