New Patient Registration
If you are a new patient, you will need to complete our Patient Registration Form. The form is designed to be completed in under 10 minutes. Please have the following information ready:
– Full Name
– Parent’s Name (if registering a child under 16 years old)
– Home Address
– Email Address(current and updated)
– Insurance Provider (Nagico, SZV, Pan American Life, Guardian Group, or Self-Pay/Cash)
– Policy Number/ID
– Phone Number (contact numbers where you can be reached)
Medical History
This section includes details on:
– Allergies (food and medication)
– Medical Conditions (e.g., Diabetes, Hypertension)
Surgical & Delivery History
If you have undergone surgery or given birth, please provide details, such as:
Example Entry:
– Date: 2018
– Procedure: Vaginal delivery of son
– Outcome: Good
– Hospital Stay Duration: 1 day
Current Medications
List all medications you are currently taking, including dosage and frequency.
Family Medical History
Provide relevant medical history of immediate family members.
Once completed, you may email the form to info-admin@fmp.sx or drop it off at our office.