NorthPoint Medical

NorthPoint Medical looks forward to having you join our host of satisfied patients. To schedule a new patient appointment, please fill out the fields below and press the submit button to forward your information to our Benefits Counselor. You will receive a call back from our Benefits Counselor to help schedule your first appointment.

If you wish, you may contact our office directly at (954) 772-2411, press option 2 and you will be connected to our Benefits Counselor who will assist you in the intake process.

Disclaimer: Information sent from this web form will be processed via a non-secure internet connection. As the sender of all private and personal information via this form you authorize Northpoint Medical to review and use said information for medical purposes ONLY and accept any potential risk associated with sending private information via a non-secure internet connection, removing all liability from Northpoint Medical for unauthorized use of any private or personal information entered and sent from this form by a third party.

First Name:

Middle Name:

Last Name:

Date of Birth:

mm/dd/yyyy

Street Address:

City State Zip:

Phone:

Cell:

Social Security #:

Insurance Provider Name (Or Cash Pay):

Insurance Type:

Member ID (Or Cash):

Group Number (Or Cash):

Sex:

Male Female

Email:

Requests:

What is/are the reason(s) for your medical visit?

Medical Conditions of which your practitioner needs to be aware:

Prior Surgeries:

Are you allergic to any medications?

Medication:	Reaction:

An accurate list of medications is necessary for your initial visit, please list all of your medications as well as their dosages. It is recommended you bring your medications to your first visit as well.

Although not all illnesses are genetic, your Physician / Physician Assistant will need to review your family's health history. Please list any illnesses that are present in your family:

Mother:

Father:

Siblings:

Other:

Do you smoke cigarettes?

Yes No

Do you drink alcohol?

Yes, socially Yes, heavy user No

What is your HIV status?

Positive Negative Don't know

What is your occupation?

Is English your primary language?

Yes No

If no, what is your primary language?

Do you have Advance Directives or a Living Will?

Yes No

Is domestic violence affecting your life?

Yes No

Additional Information: