Welcome to Freedom Wellness Centers!
New Patient Registration Form
Save 15-20 minutes of your time in our office by completing this form online.
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Are you a new patient? *

Definition:  a new patient is one who has not seen Dr. Karl Forgeron at Freedom Wellness Centers in the past three years.
     
 
Is this visit the result of a personal injury from a motor vehicle collision within the past 90 days? *

     
 
Is this visit the result of a work-related injury? *

Definition:  a work-related injury is an injury or illness caused, contributed or significantly aggravated by events or exposures in the work environment
     
 
What is your full legal name? *

 
What is your primary telephone number?

 
Is your primary telephone number your:


 
To verify and protect your identity,
please upload a copy or scanned image of your drivers' license or state ID card. *

Our website and this form are protected and secure, and your data is encrypted when submitted.  For your comfort, if you would prefer to bring your DL or ID into the office to have a copy made, then please upload a picture of something less than 10MB here.  This is a required field and you will not be able to submit the form without something in this field.
 
Which year were you born in? *

 
On which day of {{answer_24889336}} {{answer_24889334}} were you born? *

 
What is your biological sex? *



 
Please upload a current picture of yourself for our records.

We accept images in .png and .jpg formats.
 
Do you have health insurance? *

You may be covered by your workplace or a family member.


 
Are you the health insurance policy holder? *



 
What is the full name of the health insurance policy holder? *

As it appears on the heath insurance policy certificate.
 
What is the name of your health insurance company? *

 
What is your health insurance policy number? *

 
What is the street address of your insurance company?

 
What is their city and state?

 
What is their postal or zip code?

 
Is this policy associated with a HSA, FSA or HRA?

     
 
Is there coverage by an additional or secondary insurance?

     
 
Secondary Insurance Company Name:

 
What is the name of the secondary insurance company?

 
ID #:

 
Group #:

 
Subscriber Name:

 
Birth Date:

 
Relationship to Patient:

 
Please upload a copy of your medical insurance documents.

We'll check the details you provided against this document.
 
Thank you for sharing your personal and health insurance details.*
*

We now just need to ask you a few more questions for our medical records.
 
What is your blood type? *










 
Do you have any allergies? *



 
What are you allergic to? *

Be careful to list all food, environmental, or drug allergies to medication.
 
Are you taking any medications currently? *



 
Which medications are you currently taking? *

Be careful to list all of them.  If known, please indicate dosage and frequency.
 
Are you currently pregnant or is there a chance you could be? *

If you are unsure, please ask your health professional about a free pregnancy test.



 
For your unborn child's safety, Dr. Forgeron does not perform x-rays on pregnant females.

 
Would you like the doctor to perform a free pregnancy test?

     
 
How frequently do you consume alcohol?

Please be honest. Zero would be not frequently at all, and six would be extremely frequently.
 
How frequently do you smoke or use tobacco products?

Please be honest. Zero would be not frequently at all, and six would be extremely frequently.
 
Number of packs per day?

 
How many years have you smoked or used tobacco products?

 
Please enter the contact details of someone you trust.

We will contact this person in case of an emergency.
 
What is the full name of your emergency contact? *

 
What is your relationship with this person? *


 
What is their phone number? *

Please include the area code.
 
Assignment and Release *

     
 
Please confirm the following details:

*
Full name: *{{answer_24889317}}
Email: {{answer_24889326}}*
Gender: *{{answer_24889327}}
Date of birth: {{answer_24889336}} {{answer_24889335}}, {{answer_24889334}}
Blood type: {{answer_24889330}}

Health Insurance Provider: {{answer_24889319}}
Health Insurance Policy Number: {{answer_24889320}}

Emergency contact: {{answer_24889324}}
Emergency phone number: {{answer_24889325}}
Thank you.
Your patient registration profile has been submitted successfully.  Patient satisfaction is our #1 priority.  
You can save yourself additional time in our office by completing the History Form now.
If you do not have time now, click the proceed button and bookmark the page to your favorites for easy future access.
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