New Patient Registration

If you are a new patient to the practice you will be required to fill in our Patient Registration Form. The design of the registration form allows for it to be filled in, in under 10 minutes. You would just need the following information when filling in the form:

• Your name
• Parents name (if the form is for a child under the age of 16 years)
• Address (your home address)
• Email (an updated email address)
• Insurance (the type of insurance that will be used: Nagico, SZV, Pan American Life, Guardian Group, or Self Pay/Cash)
• Policy Number/ID
• Phone Number (telephone numbers that you can be reached on)

The Medical History follows after that section of the form and asks for information such as Allergies to food/medication and if you have any medical conditions such as Diabetes or Hypertension.

The Surgical/Delivery History section should be filled in if you have any surgeries in the past or if you have had any deliveries of children either via C-Section or via Vaginal Delivery. Here is an example of how to fill in this section:

Date: 2018

Procedure: Delivery of Son (vaginal)

Outcome: Good

Duration of Stay: 1 day in hospital

The Medications Currently Prescribed Section is where you would list all of the medication that you currently take. The Family History section of the form is filled in according to your family history.

When you have completed the form you can email it to: info-admin@fmp.sx or you can drop the form off at the office. Patient Registration Form