Obgyn lewis gale salem va patient registration forms 2026

1. Click ‘Get Form’ to open the patient registration form in the editor.
2. Begin by circling your title (Dr., Mr., Mrs., Ms., Miss) and filling in your name and date at the top of the form.
3. Complete your address, city, state, and zip code. Then, provide your age and date of birth.
4. Fill in your occupation and employer details, along with home, work, email, and cell phone numbers.
5. If applicable, provide your spouse's name and employer. List any children living at home along with their ages.
6. For patients under 18, include parent names and employers. If you are a student, note the school or college name.
7. Add an emergency contact's name and phone number. Indicate how you were referred to the clinic.
8. In the General History section, list your primary care physician and any medications you are currently taking.
9. Circle any relevant health conditions from the provided list that apply to you.
10. Complete the Family History section by circling applicable conditions affecting family members.
11. Provide personal eye information including the date of your last eye exam and any relevant eye conditions or surgeries.
12. Finally, read through the authorization statement carefully before signing it at the bottom of the form.

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