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Patient Registration

* Required











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INSURANCE INFORMATION
We will request to scan your ID and insurance card and Drivers license.




INSURED INFORMATION (IF OTHER THAN PATIENT)






RELEASE OF INFORMATION
I hereby give permission to the person listed below to receive information about the above named patient.



EMERGENCY CONTACT



SIGNATURE OF PATIENT OR RESPONSIBLE PARTY GRANTING PERMISSION TO TREAT
Just put your initials here!


Health History





MEDICAL INFORMATION
Please list any medications you are currently taking, prescribed or over the counter.
(Ask for extra paper if needed to complete medication list.)

























For Females:








For Males:

SOCIAL INFORMATION


















If YOU or a FAMILY MEMBER has had any of the following, please circle and specify
if it is self or family member, and for how long did you have it?
Allergies Anemia Angina Anxiety Alcoholism Arthritis Asthma Atrial Fibrillation Benign Prostatic Hypertrophy Blood Clots Cancer Cerebrovascular Accident Coronary Artery Disease COPD Crohn’s Disease Depression Diabetes Fractures Gynecological Disease Gallbladder Disease GERD (Reflux) Heart Attack Hepatitis High Blood Pressure High Cholesterol High Cholesterol Irritable Bowel Disease Kidney Disease Liver Disease Migraine Headaches Neurological Disease Osteopenia/Osteoporosis Peptic Ulcer Disease Respiratory Disease Skin Disease Stomach/Colon Disease Stroke Seizure Disorder Thyroid Disorder Sexually Transmitted Disease










Note:
All questions and whole Patient Registration and everything in our office is HIPPA compliant and confidential, and it is information only for you and your doctor, and to help you with your health. Also, all of us in our office will do our best to help you, and we respect equally all of our patients, regardless of sex, race, color, religion or creed.
And just to let you know, I did take Hippocratic Oath, and I take very seriously my calling of being a Family Physician and Geriatrician.
Thank you for choosing our office for all yours and your family medical needs, Dr. Neskovic

Spasoje M. Neskovic, M.D.
Family Practice and Geriatrics- when needed call us always at 818-244 4114, our main office number first, but if something is urgent you can call me at my Private line 818-244 2022.

Ashley, Medical Receptionist call at 818-244 4114
Danika, Medical Assistant call at 818-244 4114