EXPHS Patient Registration

EXPRESS HEALTH SYSTEMS

Patient Registration

Patient Name *

First Name (as appears on License/Identification)

Last Name (as appears on License/Identification)

Middle Name (optional)

Maiden Name (if applicable)

Date of Birth *

Address * Street Address

Street Address Line 2

City

State

ZIP Code

Gender * Male Female

Email Address *

Phone Number *

Were you referred to Express Health Systems by another Patient? * Yes No

If you wish to receive any information or promotions from Express Health Systems: * No Thank You Email Text (carrier charges may apply) Mail

Social History - Check all that apply: *

None Cigarettes Smokeless Tobacco Alcohol Consumption Illicit Drugs

Review of Symptoms - Check all that apply: *

None Swelling Fatigue Skin, Hair, or Nail Problems Excess Weight

Eating Habits - Check all that apply: *

None Large Portions Sweets/Snacks Carbonated Drinks

Allergies to Medications: * Yes No

Allergies to Food: * Yes No

Current medications, supplements, vitamins, or herbs:

Please add only ONE item per row.

Do you exercise? * Yes No

EXPRESS HEALTH SYSTEMS

Acknowledgement: * By signing below, I agree to the Terms and Conditions of Service

Patient Signature *

Use your mouse or finger to draw your signature above

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