Are you a new patient or an established patient with Ambucare?
Please choose
Check in Time
Account #
Personal Information
First Name
Middle Initial
Last Name
Gender
Date of Birth
Marital Status
Preferred Language
Race
Ethnicity

SYMPTOMS Please note any current symptoms you are experiencing
Symptoms
Medicine/Allergies:
Current Medication you are taking:
Which Pharmacy Do You Use?
Tobacco Use:
Alcohol Use:
Do you have a history of seasonal allergies?
Do you have a history of asthma?

Date of last colonoscopy:
Normal?

Females
Date of last Pap:
Normal?
Date of last Mamogram:
Normal?

Males
Date of last prostate exam
Normal?

If you have an existing primary care physician, please enter their name below:
Primary Care Physician

Contact Information
Street Address
City
State
Zip
Home Phone
Work Phone
Cellphone
Fax
Social Security #

How do you prefer we contact you?
Contact me by:

Address, City, State, Zip
Phone

Patient’s Employer:
Address, City, State, Zip
Phone

Emergency Contact:
Address, City, State, Zip
Phone
Relationship to Patient

Insurance Information
Primary Insurance Company
Main Card Holder’s Name
Social Security
Date of Birth

Secondary Insurance Company
Main Card Holder’s Name
Main Card Holder’s Name
Date of Birth

How did you hear about us?
Other?