New Patient Form - Calimed Wellness Center

We greatly appreciate your help in getting the best information about yourself (or your family member) by filling out as much information as possible. We look forward to giving you back with the best medical service you’ve ever received. The CaliMed Team.

We comply with the HIPPA regulations of the United States which do not share your data with third parties.

English

Español

Portuguese

Patient Information:

First Name*

Middle Name

Last Name*

Date of Birth (Insert the following format: MM / DD / YYYY)

Age

Gender

Country of Birth

City of Birth

Social Security Number (Insert the following format 123-45-6789)

Patient Record Number

Form of Identification

Identification Document Number

Contact Information:

Mobile

Home Phone

Work Phone

Email*

Address

Unit/Apt Number

City

State

Zip Code

Preferred Method of Contact

If patient is < AGE 18, provide info about Parent/Guardian (P/G):

P/G First Name

P/G Last Name

P/G Address

P/G Unit/Apt Number

P/G City

P/G State

P/G Zip Code

P/G Mobile

P/G Email

Information of Emergency Contact:

Complete Name Of Emergency Contact

Relation Of Emergency Contact to Patient

If Other, Specify

Contact Phone Number Of Emergency Contact

Contact Address Of Emergency Contact

Unit/Apt Number Of Emergency Contact

City Of Residence Of Emergency Contact

State Of Residence Of Emergency Contact

Zip Code Of Emergency Contact

Payment Method:

Cash	Credit Card	Debit Card	Gift Card
eTransfer	Insurance	CaliMed Medical Plan (Membership)

If using insurance, provide this information:

Insurer/Payer

Group

Insured Identification

Policy Holder´s Name

Policy Holder´s Date of Birth

Policy Holder's Address

Policy Holder´s Phone

Prescriptions (Preferred Pharmacy):

Pharmacy Name

Pharmacy Address/Plaza/Zip Code

Pharmacy Phone

Pharmacy Fax

Demographic Data:

Race

Ethnicity

Nationality

Preferred Language

If Other Selected, add Language

Gender Identity

Other Members of the Care Team:

Provider Name 1

Provider Speciality 1

Provider Phone 1

Provider Fax 1

Provider Name 2

Provider Speciality 2

Provider Phone 2

Provider Fax 2

Provider Name 3

Provider Speciality 3

Provider Phone 3

Provider Fax 3

Provider Name 4

Provider Speciality 4

Provider Phone 4

Provider Fax 4

Reason for Consultation (In your own words):

Description

Query Options:

New Patient	Follow Up Visit	Physical Exam	Birth Control	Varicose Veins
Skin/Hair Problems	Low Testosterone	Hormone Therapy	Thyroid Disease	Low Libido
Aesthetic Dermatology	Weight Loss Program	IV Infusion Therapy	Erectile Dysfunction	Immigration Exam
Urgent Care	Prescription Refill	Hair Loss Prevention	Anxiety/Depression	Sleep Problems

Past Medical History:

Pre-Existing Medical Conditions

Previous Surgeries / Procedures

Allergies (Drugs/Food/Environment/Type of Reaction)

Current Medicines (Name/Dosage)

Social History:

Tobacco Use

If Smoker, How many cigarettes/day do you smoke?

Alcohol Use

Physical Activity

If Yes, How many days/week do you exercise?

If Yes, How many minutes/day do you exercise?

Family History (Which family member(s) suffer of):

Headaches

Cancer

Heart Disease

Hypertension

Diabetes

High Cholesterol

Liver Problems

Stroke

Arthritis

Osteoporosis

Seizures

Kidney Problems

How did you find out about CaliMed & Dr. Pardo, NP?

Google	Instagram	Facebook	LinkedIn
Tik Tok	YouTube	Websites	Referral

Who Referred you to us (Provide us his/her name)?

Do you have Primary Care Provider?

CANCELLATION POLICY

In the event you are unable to make your appointment, we do require 24 hours notice to cancel or reschedule to avoid being assessed the $25 fee for missed/no-call, no-show appointments.

During non-business hours, patients can contact us by phone at (954) 625-0587 to leave a voicemail or an email can be sent to info@calimedwellness.com to notify us of your intention to cancel.