New patient forms

Fill it out at home.
Print it and bring it with you.

The forms have two parts — patient registration and medical / social history. Answer as much as you can; anything you leave blank we'll finish together at the office.

Secure online submission is temporarily unavailable.

Complete the form on a private device, then print it and bring it to your appointment. If you save a PDF, store it in a secure location and do not send it by ordinary email.

Patient registration

Contact, guarantor, emergency and insurance details.

Patient information

Full legal name (first, middle, last, suffix)

Nickname

Sex

Date of birth

Social security number

Race

Preferred language

Ethnicity

Marital status

Complete mailing address

Street, city, state, ZIP code, county

Home phone number

Cell phone number

Work number

Employment status

Retirement date (if retired)

Employer name

Employer phone number

Employer complete address

Street, city, state, ZIP code

Spouse or guarantor information

Responsible party. Check the box below if this is the same as the patient.

Same as patient

Full legal name (first, middle, last, suffix)

Date of birth

Social security number

Relation to patient

Sex

Home phone number

Cell phone number

Work number

Complete mailing address — if different from patient

Street, city, state, ZIP code, county

Employment status

Retirement date (if retired)

Employer name

Employer phone number

Employer complete address

Street, city, state, ZIP code

Emergency contact information

Name (first, last)

Relation to patient

If other, please specify

Home phone number

Cell phone number

Work number

Complete mailing address — if different from patient

Insurance information

Please bring your insurance card and a photo ID to your appointment.

Self-pay (no insurance)

Primary insurance

Patient relation to subscriber

Secondary insurance

Patient relation to subscriber

Prescription / Rx provider

If different from insurance carrier

Full name of subscriber

Complete below if different from patient, spouse or guarantor

Subscriber date of birth

Employment status

Retirement date (if retired)

Employer name

Employer size

Employer complete address

Street, city, state, ZIP code

Care preferences

Primary care physician

Do you want anyone to know you are here?

Medical / social history

Allergies, medications, past illnesses, family and social history.

Patient & referring providers

Full name

Date of birth

Today's date

Primary doctor

Doctor who requested today's visit

List current / previous doctors and their specialty

Allergies & medications

Allergies and reactions

Medications

List dosage and how you take them, including non-prescription, supplements, herbs and birth control.

Operations & hospitalizations

Operations and hospitalizations

	Operation	Date	Hospitalization	Date
1
2
3

Family health history

Adopted

Family health history

	Major medical problems	If deceased, cause
Maternal grandmother
Paternal grandmother
Maternal grandfather
Paternal grandfather
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Child 1
Child 2
Child 3

Social history

Occupation

Marital status

Children

Do you drink alcohol?

How often?

How many drinks?

Do you smoke?

Packs per day

How many years?

Are you a former smoker?

Year quit?

Do you chew tobacco?

Do you use recreational / illegal drugs?

Do you have a living will?

Healthcare proxy?

If so, who?

Reasons for your visit

Please list all reasons for visiting today, in order of priority.

Signature

Patient name (print)

Date (MM/DD/YY)

Time

Relationship to patient (if signing for patient)

Reason patient is unable to sign

Appointments

We schedule by phone or physician referral.

Call the office and our front desk will find you a time, confirm your insurance and tell you exactly what to bring to your first visit.

Call 404-355-1799

Address

371 East Paces Ferry Rd NE, Suite 525
Atlanta, GA 30305

Hours

Monday – Thursday — 8:00 am – 4:00 pm

Friday — 8:00 am – 3:00 pm

Saturday & Sunday — Closed

Fax

404-355-4788

Fill it out at home.Print it and bring it with you.

Buckhead Rheumatology — New Patient Forms

We schedule by phone or physician referral.

Fill it out at home.
Print it and bring it with you.