Dr.Tierce New Patient information

It's a LOT better to fill this form out at your leisure than trying to cram them in at the beginning of a visit - take your time - give us more rather than less ( spelling is NOT graded !!) The head nurse and office manager review personally the day you fill it out, and will get you in earlier if you need it. If the doctors feel you would be more efficiently seen by a different type of doctor, we will advise you because we can tell with this information, if we are going to make a difference.

Your home street address *

City *

State *

Zip Code *

Best phone number *

Who is the subscriber
(Name on the insurance policy) *

Date of birth of the subscriber
(Name on the insurance policy ) *

Insurance Carrier *

Insurance ID# *

Insurance GROUP number *

Secondary Insurance *

Insurance ID# *

What kind of work-up do you want *

How did you choose
this office *

Please plan on spending at least 1.5 hours in this visit. The exam rooms are small, please limit the number of people you bring to the absolute minimum - if possible, place other children with alternative care so you may - we are under severe waiting room restrictions. Feel free to bring a recording device if there are other family members who want to hear what is said.Make plans to be here a bit early - if you are late, we may have to reschedule - no kidding.

FIRST NAME: *

LAST NAME: *

Profession (if minor name and
profession of parents) *

Do you already have an appointment
scheduled *

DATE OF BIRTH *

Age *

GENDER: *

WHO IS YOUR
PRIMARY CARE ? *

name of referring physician
to send report *

WHICH PHARMACY DO YOU USE
WITH PHONE IF POSSIBLE
LOOK ON AN OLD BOTTLE *

Email Address *

WHY ARE YOU COMING - THIS IS CRUCIAL.

This is an expandable box for an essay. Take your time - unload everything about your concerns and the expected result of being seen and evaluated. We are after what the FOCUS of the visit should be, a priority list ( #1 problem, #2 Problem # 3 etc) . For this emergency time, we may be able to analyze your case and order your lab work before you physically come in to the office. Let us know if you want to exercise that option.

*

0 characters

MEDICAL CONDITIONS
INCLUDING PAST SURGERIES *

HAD PREVIOUS
BLOOD OR
SKIN TESTS
FOR ALLERGY? *

Ever been on allergy
shots or drops? *

Have you ever had a
Pneumonia shot? *

HAVE YOU HAD
YOUR FLU SHOT *

USE AFRIN
SPRAYS? *

DO NASAL STEROID
SPRAYS HELP *

EVER SMOKED - how long
When did you quit? *

DO ANTI-
HISTAMINES
HELP? *

WHAT IS THE
WORSE ALLERGY SEASON *

IS THERE ALLERGY
IN YOUR FAMILY? *

INDOOR PETS *

Are your eyes *

Itchy

Burny

swollen

normal

Is your nose *

Congested

itchy

drippy

normal

Does your throat
bother you *

sore

hoarse

drainage

normal

Is your chest *

Does your heart *

hurt (chest pain)

skip beats

normal

Heartburn or reflux? *

yes

no

Are you *

sleeping poorly

anxious

mildly depressed

no issues

Is your skin *

itchy

dry

rashy

other

LIST MEDICATIONS *

LIST ANY MEDICINE
REACTIONS OR ALLERGY *

Do you want to do this
by telemedicine *

You can submit now - here is who will greet you!!