Appointment Request

Thank you for your interest in our services. Please fill out the information below, and one of our team members will contact you to schedule an appointment time. We look forward to seeing you soon.

_2017 Adult Registration Form – Medical

PATIENT INFORMATION

* Gender:

PERSON RESPONSIBLE FOR ACCOUNT (If patient is a minor please complete next section)

INSURANCE INFORMATION

IN CASE OF EMERGENCY, WHO SHOULD WE CONTACT?

MEDICAL HISTORY

Months Affected?
* How many colds do you have each year?
Do any of the following cause or make your symptoms worse. Please check what you have noticed to bother you or make your symptoms worse.
Do any of the Foods listed below cause Hives, itching of the lips or throat, or any more severe symptoms after handling/ingestions?

FAMILY HISTORY

Please provide the following: Living/Deceased, Age, Medical Conditions/Cause of Death

ENVIRONMENTAL HISTORY

Please indicate contents of furnishings in your environment:
Bedding:
Allergy control Encasements on:
Window Treatments:
Have you had any new Environmental changes, books, trophies, stuffed animals, games, collections at:
Please check any below that you have or have had in the past.

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Kevin P. McGrath, M.D.

  • Kevin P. McGrath, M.D. - 912 Silas Deane Hwy., Suite 100, Wethersfield, CT 06109 Phone: 860 257 3535

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