New Patient Registration

First Name

Birthday

Last Name

SSN

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Community, if applicable

Does the Patient have a Power of Attorney?

Yes

Relationship to Patient

POA First Name

POA Last Name

POA Email

POA Phone Number

POA Address

Primary Insurance

Primary Insurance Policy Number

Secondary Insurance

Secondary Insurance Policy Number

Previous Primary Care Provider

Specialty Providers Involved in Patient's Care

Medical Diagnoses

Current Medications

Previous Surgeries (include year of surgery)

Additional Information

Please upload any documents (ID cards, insurance cards, POA forms, medication list, etc.) Please contact our office if you need a specific form.

Upload File

Required: Please click box to read policies and check boxes below.

I have read and agree to the Financial Policy and I understand that I am responsible for the fees.

I have read and agree to Lykos Medical's HIPAA Compliance Policy

Is the patient signing on their own behalf?

Yes

Name of Patient's representative/caregiver signing this form

Signature

By signing and submitting this form to Lykos Medical, I am consenting to care from a Lykos Medical provider.

Registration Complete!