orthPoint 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 New Patient Coordinator. You will receive a call back from our New Patient Coordinator 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 New Patient Coordinator who will assist you in the intake process. 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: SELECT CASH HMO POS EPO PPO Indemnity 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: