Vanguard Geriatrics
Create Patient Registration

  marks the required fields

Are you the patient?
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Contact:
If you are NOT the patient, please give us your information.
Relationship to the patient?
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Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
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Work Phone:		- -   ext.
Home Phone:		- -   ext.
Cell Phone:		- -   ext.
Pager:		- -   ext.
Fax:		- -   ext.
Email:
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Street (mailing address):
Suite / Apartment:
City:
State:
Zip Code:
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Do you have power of attorney for healthcare?
Power of Attorney:
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Patient Information:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
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Work Phone:		- -   ext.
Home Phone:		- -   ext.
Cell Phone:		- -   ext.
Pager:		- -   ext.
Fax:		- -   ext.
Email:
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Street (home address):
Suite / Apartment:
City:
State:
Zip Code:
Type of Residence:
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Gender:
Date of Birth:
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Marital Status:
Ethnicity:
Primary Language:
Religion:
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Your Social Security, Medicare, and Medicaid numbers are not required for inquiries. A Staff member will call you when they are required.
Social Security #:
Medicare #:
Medicaid #:
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Insurance: (Primary)
What types of insurances do you have?
Company #1:
Company #2:
Company #3:
Other:
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Insurance: (Secondary)
What types of secondary insurances do you have?
Company #1:
Company #2:
Company #3:
Other:
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Medical
Does the patient have an advance directive?
Advance directive:
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Has the patient been to the hospital within the last 30 days?
Within 30 days:
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If Yes, where and for what reason?
Where / Reason:
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Surgical History
Tell us about your surgical history.
Appendectomy:
Endartectomy:
Endocarectomy:
Hysterectomy:
Mastectomy-Left Breast:
Mastectomy-Right Breast:
pacemaker:
Rhinoplasty:
Thyroidectomy:
TURP:
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Medical History
Tell us about your medical history.
Alzheimer's:
Anemia, other, unspec. (285.9):
Angina pectoris, NOS (413.9):
Asthma:
Atrial fibrillation (427.31):
Breast Cancer L Breast:
Breast Cancer R Breast:
Diabetes:
Hearing loss, unspec. (389.9):
Heart Murmur:
Polycythemia vera (238.4):
Sickle-cell anemia 282.60:
Sickle-cell disease, unspec (282.60):
UT:
Uterine fibroid:
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Medication
Are you taking medications?
(If yes, please list them below.)
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		Name:		Dosage:		Time(s):
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
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Primary Physician:
Please tell us about your primary physician.
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Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
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Work Phone:		- -   ext.
Home Phone:		- -   ext.
Cell Phone:		- -   ext.
Pager:		- -   ext.
Fax:		- -   ext.
Email:
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Street (mailing address):
Suite / Apartment:
City:
State:
Zip Code:
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Is your doctor making a referral to Vanguard Geriatrics?
Doctor Referral:
Self Referral:
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How did you hear about Vanguard Geriatrics?
Source:
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Services Needed
What type of services would you like Vanguard Geriatrics to provide you with?
Alzheimer's Memory Care Facility Secure:
assisted living:
in-home care:
Nursing Home Care:
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Tell us more about your needs and expectations.
Situation:
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When would you like Vanguard Geriatrics to begin providing medical care to you?
Date:
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When is the best time to contact you?
Time(s):
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By submitting this form to Vanguard Geriatrics you authorize vanguard geriatrics to contact you regarding providing your medical care. One of our representatives will be contacting you. Thank you Vanguard Geriatrics, Inc.
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