New Patient Form

Patient Update Form

Someone from NGMH will be in touch in 24 hrs . For updates, please fill in ONLY what needs to be be updated to your chart. Thank you!

Patient Name:

First Name

Last Name

Phone:

Primary phone

(###)

###

####

Date Of Birth DOB:

YYYY

Social Security

Driver License State and Number:

Home Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email:

Occupation

Employer:

Employer Phone:

(###)

###

####

Emergency Contact Name:

Emergency Contact Relation:

Emergency Contact Number:

Birth Gender:

Age

Height

Weight

Marital Status:

Ethnicity:

Hearing Impaired?:

Yes

Visually Impaired?:

Yes

Primary Care Physician:

Phone

(###)

###

####

Fax #

Referring Physician:

Phone

(###)

###

####

Fax #

Reason For Visit:

Chief Complaint and Concerns in your own words

Basic vitals

Current Temperature, Blood pressure, Pulse, Respiration, Blood type, if possible

List ALL Current Medications over the past year:

prescribed and over the counter

Anything else we should know?:

Pharmacy Name:

Pharmacy Phone:

Pharmacy Fax:

Pharmacy Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Health Care Proxy Name:

First Name

Last Name

Health Care Proxy Relation:

Health Care Proxy Phone:

Primary Insurance:

Primary Subscriber Name:

First Name

Last Name

Primary Subscriber Home Phone:

Primary Subscriber Cell Phone:

Primary Subscriber Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Subscriber ID Number:

Primary Group Number on Insurance Card:

Primary Phone # on Back of Card:

Primary Subscriber Email:

Patient Relationship to Policy Holder:

Secondary Insurance:

Secondary Subscriber Name:

First Name

Last Name

Secondary Subscriber ID Number:

Secondary Group Number on Insurance Card:

Secondary Phone # on Back of Card:

Secondary Patient Relationship to Policy Holder:

Medical records to our office prior to your first visit. As many years as your physician or you feel are necessary. If you have copies, you're welcome to bring them. Including imaging discs, dvd's, x-rays. Thank you!

Fax: (212) 954-5119

Required photos of the front and back of your Insurance card and Driver's license can be emailed prior to your visit. SMS is available, carrier charges may apply. Please see our Contact US page for details..

Email: Info@nextgenmed.co

I attest the above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the attending physician. I authorize that payment of all third-party benefits otherwise payable to me be made directly to Next Generation Medical Healthcare, PLLC. I understand that I am financially responsible for any balance and or co-pays per my insurance agreements. I authorize my Insurance company and NGMH, PLLC to release information required on my behalf to process claims through the current biller, including medical records. The transmission of all information may be done electronically, fax, email, via Internet.

My clicking this box and submitting the above form, I've read and provided all information, freely and understand the purpose of this form. Privacy policy and SMS policy applies as stated on website.

New Patient Form

Patient Update Form

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