United Critical Care Lung & Sleep Medicine

New Patient Registration Form

Thank you for considering United Critical Care Lung and Sleep Medicine. Please complete this New Patient form and upon receipt you will receive a call to reserve your appointment time. We believe in getting to know our patients so our practice does not "overbook" patients (the common practice of scheduling 2 patients in the same time slot to compensate for patients that do not show up) .The 30 minute time slot set aside for your new patient appointment belongs to you and you only, so you can receive a thorough consultation with the provider. To provide timely appointments for those seeking pulmonary/sleep medicine care and not participate in overbooking our practice charges a $150 no show fee for cancellations of new patient appointments less than 48 hours in advance. You will be asked to sign the financial policy below in this form to indicate your acceptance of this policy. We look forward to your visit .If you have any questions, please contact the office at 702-476-4900.

Patient Information

First Name * Last Name * Date of Birth * SSN Sex * Mailing Address * City * State * Zip Code * Cell Phone * Home Phone Email Address * Pharmacy Name * Pharmacy Address *

Additional Information

Preferred Language * Occupation * Emergency Contact Name * Emergency Contact Relation * Emergency Contact Number * How Did You Hear About Us? * Referring Doctor's Name

Primary Insurance

Primary Insurance Name * Policy ID * Group ID * Policy Holder's Name * Policy Holder's DOB * Policy Holder's SSN * Patient Relationship to Policy Holder *

Secondary Insurance Information

Secondary Insurance Name Policy ID Group ID Policy Holder's Name Policy Holder's DOB Policy Holder's SSN Patient Relationship to Policy Holder

Medical History

Please Describe the reason for your visit to a Lung/Sleep Specialist * Please check all that apply * Other Type of Cancer Other Please list all medications you are currently taking, dose and frequency. * Please list any allergies and reaction. *

Social History

Do you smoke? * How many cigarettes per day? Any other forms of tobacco? List Do you drink alcohol? How often? Do you use any illicit drugs?

Family History

Does anyone in your family (living or deceased) have the following:

Please check all that apply Other Other

Surgical History

Please select/list all surgeries:

Please check all that apply: New Field65