Weight Loss New Patient

We would like to formally welcome you to our practice! We look forward to being your providers for both medical and aesthetic needs.
In order to provide the best care possible, we need to collect some information about you. If you have any questions or concerns - please do not hesitate to ask!

WELCOME!
The team at Clearwater Primary Care & Aesthetics
(Florida Family Medical Center)

Name(Required)

D.O.B(Required)

Age(Required)

Gender(Required)

Male

Female

Primary Language(Required)

Translator Needed

Yes

No

Purpose of initial visit(Required)

Weight (in Pound)(Required)

Height (in cm)(Required)

Do you have any ALLERGIES?

Drug Allergies(Required)

Aspirin NSAIDS Penicillin Sulfa Contrast Dye Iodine

None

Food Allergies(Required)

Peanuts Soy Wheat Tree Nuts Shellfish Fish Strawberries

None

Environmental Allergies(Required)

Latex Bees Wasps Cats Dogs Grass Pollen

None

Are you in good health at the present time of the best of your knowledge ?(Required)

Yes

No

If no, please explain(Required)

Are you under a doctor's care at the present time ?(Required)

Yes

No

If yes, whom and for what?(Required)

Name of preferred pharmacy?

Location

Do you take any medications or supplements on a daily basis? If yes please list below:

Name

Strength

How Often ?