Primary Intake | NM Wellness

PATIENT INFORMATION

Full Name

DOB

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

INSURANCE INFORMATION

Primary Insurance

Member ID

Group Number

Placeholder

MEDICAL HISTORY

PAST SURGICAL HISTORY AND HOSPITALIZATIONS

List past surgeries, fractures and hospitalization.

CURRENT SYMPTOMS (Check all that apply)

Urinary (Myrbetriq)

Frequent urination

Urinary urgency

Urinary leakage/incontinence

Difficulty holding ur

REVIEW OF SYMPTOMS

MEDICATION

List prescriptions, over-the-counter medications, vitamins, supplement, and include any trail medication failures and dates.

ALLERGIES

Allergy + Reaction

FAMILY HISTORY

Long answer

SOCIAL HISTORY

PHARMACY

Pharmacy

Phone

UPLOAD DOCUMENTS

Insurance Card

Photo ID

CONSENT AND SIGNATURE

I certify that the information provided is accurate to the best of my knowledge. I authorize NM Wellness in Family Health NP PLLC to use this information for treatment, payment, healthcare operations, referrals, and insurance verification as permitted by law.

By checking this box, you agree to receive SMS messages from NM Wellness In Family Health related to customer care, appointment reminders, scheduling, billing, and other healthcare-related communications. You may reply STOP at any time to opt out. Reply HELP for assistance. Message and data rates may apply. Message frequency may vary. Learn more in our Privacy Policy and Terms & Conditions.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

NM

N.M Wellness

IN FAMILY HEALTH

212-347-5887

37 East 30th Street
New York NY 10016

Fax: 702-974-8629

NEW PATIENTS · PRIMARY CARE

Primary Care Intake

Tell us about your health history and reason for the visit. Submitted securely to our office.

NM

NM Wellness

IN FAMILY HEALTH