New Patient Registration for Primary Care: Join Our Clinic Today

Mon - Fri 8:15-4:00PMSat & Sun - CLOSEDPrimary Care - text (904) 513-3240Pain Management - text (904) 206-71322624 Atlantic BlvdJacksonville, FL 32207

Please complete the information below. Once submitted, our office will contact you within one business day to schedule your appointment. If you have an emergency, call 911 immediately or go to your nearest emergency room. We do not respond to emergencies through this website.

If you’d like to download & print the form you can do so here:

New Patient Registration Packet | En Español

Name*
First Middle Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
Sex:*
- Male
- Female
NO SHOW/LATE CANCELLATION APPOINTMENT POLICY*
- I Have Read & Agree that: We, at Emed Multispecialty Group, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). For your convenience, there are several options available to cancel your appointment. (1) Call us at (904) 513-3240 during our normal business hours. (2) If you call after hours, our after-hour phone service is available to assist you. (3) Download the HEALOW app for access to cancel or make an appointment. To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, we will attempt to send an appointment reminder call/text at least (1) business day prior to your scheduled appointment. Please ensure we have your updated phone number on file. However, it is the responsibility of the patient to arrive for their appointment on time. PLEASE REVIEW THE FOLLOWING POLICY: • Please cancel your appointment with at least a 24 hours’ notice: There is a waiting list to see the Providers at Emed and whenever possible, we like to fill cancelled spaces to shorten the waiting period for our patients. • If less than a 24-hour cancellation is given this will be documented as a “No-Show” or “Late Cancellation” appointment and will be assessed a $20.00 no show or late cancellation fee. I have read and understand Emeds No Show/Late Cancellation Appointment Policy and understand my responsibility to plan appointments accordingly
Consent for Telemedicine Appointment*
- I Have Read and Agree that: Telemedicine is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telemedicine consultation with a Provider, details of your medical or health history and personal health information may be discussed using interactive audio, video, and/or other telecommunications technology, and the Provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or other legal document. The telemedicine services you receive from Emed Multispecialty Group are not intended to replace a primary care physician relationship, be your permanent medical home, or be used during a medical emergency. If you think you are having a medical emergency, you should dial 911 immediately. You should seek emergency help or follow-up care when recommended by a provider, symptoms worsen, or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended. We may make arrangements for follow-up care either through Emed Multispecialty Group, your primary care provider, or other health care providers. If the transmission fails during your telemedicine consultation with a provider, then every attempt will be made to contact you to help you get reconnected. You will have direct access to Healow and Emed Multispecialty Group services to follow-up on medication reactions, side effects, or other adverse events. Among the benefits of Emed Multispecialty Group via Healow is improved access to health care professionals and convenience. However, there are potentials risks associated with the use of telemedicine. These risks include, but are not limited to: 1. In some instances, the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.) 2. Delays in evaluation or treatment could occur due to failure of the electronic equipment; 3. In some instances, a lack of access to all of your medical records could result in adverse drug reactions or allergic reactions or other judgment errors; 4. Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information. I, (Patient Name) have read the information, or have had it read to me, and have received a copy of this agreement. I understand my responsibilities and agree to the above conditions while receiving opioid medication.
Social Security Number:*
Marital Status:
- Single
- Married
Phone (Cell)
Phone (Home)
Address
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Emergency Contact:
Name:*
Relationship*
Emergency Contact Phone*
Primary Insurance Information:
Carrier/Insurance Name:
Member/Policy Number:
Subscriber Information:
- Self
- Other
If "Other" individual, name and date of birth of individual:
Medicare Member #:
(only complete if you have Medicare)
Florida Medicaid Member #
(only complete if you have Florida Medicaid)
Secondary Insurance Information:
Carrier/Insurance Name:
Member/Policy Number:
Subscriber Information:
- Self:
- Other:
If "Other" individual, name and date of birth of individual:
Current Medical Conditions
Do you have any CURRENT conditions you are being treated for?*
- Yes
- No
Current Conditions Questions
Please choose “yes” if you are CURRENTLY being treated for any of these conditions.
Anxiety*
- Yes
- No
Choose any symptoms you are having related to anxiety:*
- Agitation
- Feeling Overwhelmed
- Insomnia
- Palpitations
- Guilt
- Hopelessness
- Loss of interest
- Fatigue
Depression*
- Yes
- No
Choose any symptoms you are having related to depression:*
- Agitation
- Feeling Overwhelmed
- Insomnia
- Palpitations
- Guilt
- Hopelessness
- Loss of interest
- Fatigue
Asthma*
- Yes
- No
Symptoms:*
Made worse by:*
What makes it better:*
Frequency of episodes:*
When were you diagnosed:*
Are you on medication?*
- Yes
- No
High Cholesterol*
- Yes
- No
Check any symptoms you are having related to your cholesterol:*
- Numbness
- Tingling
- Headache
- Fatigue
- Blurry Vision
- Chest Pain
- Shortness of Breath
- Ankle Swelling
- Dizziness
Heart Disease*
- Yes
- No
Check any symptoms related to your heart disease:*
- Current Smoker?
- History of Diabetes?
- Dizziness
- Previous stent placement
- Chest pain?
- Weakness?
- Headache?
Intestinal Problems*
- Yes
- No
Check any current symptoms you have related to your intestines:*
- Abdominal Pain?
- Anorexia
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Indigestion
Arthritis*
- Yes
- No
Where is your arthritis located?*
Check all that apply related to your arthritis:*
- Currently on medications?
- Joint pain
- Joint swelling
- Joint weakness
- Morning stiffness
- Fevers?
Allergies*
- Yes
- No
What symptoms do you have?*
What makes allergies worse?*
What makes allergies better?*
How long have you experienced symptoms?*
Frequency of allergic episodes?*
Are you currently on allergy medications?*
- Yes
- No
Diabetes*
- Yes
- No
What type of diabetes do you have?*
- Type 1
- Type 2
Check any symptoms you have related to your diabetes?*
- Fatigue
- Frequent urination
- frequently hungery
- thirsty
- Blurry vision
- Dizziness
- Weight loss
- Numbness
High Blood Pressure*
- Yes
- No
Check any symptoms you have related to your high blood pressure?*
- Chest pain
- Headache
- Blurred vision
- Dizziness
- Shortness of breath
Hypothyroidism*
- Yes
- No
Are you on medication for your hypothyroidism?*
- yes
- no
Check all symptoms you have related to your hypothyroidism:*
- Weight gain
- Dry skin
- Constipation
- Cold sensitivity
- Irregular menses
- Depression
- Hair loss
Other Conditions:
Past Medical History
Current Medications
Please list CURRENT medications you are taking.
Medical History*
Choose all that apply to you.
- Abuse
- Abnormal PAP
- Anemia
- Anxiety/Nerves
- Asthma
- Allergies
- Alcoholism/substance use
- Bleeding Disorder
- Blood transfusion
- Blood Clots
- Cancer
- High Cholesterol
- Chronic Pain
- Depression
- Diabetes
- Epilepsy
- Genetic Disease
- Glaucoma
- Gout
- Migraines
- Heart Disease
- Hepatitis
- High Blood Pressure
- Intestinal problems
- Kidney Disease
- Lung Disease
- Osteoporosis
- Sexual disease
- stroke
- Thyroid disease
- Tuberculosis
- Stomach ulcer
Allergies
- None
- Penicillin
- Sulfa Drugs
- Latex
- Contrast Dye
- Aspirin
- Seasonal Allergies
- Other:
Other Allergies:*
Past Surgical History
- Appendectomy
- Tonsilectomy
- Hysterectomy
- Gallbladder Removal
- Heart Surgery/Cath
- Vasectomy
- Hernia Repair
- Amputation
- Tumor Removal
- Mastectomy
- C-Section
- Back Surgery
- Colectomy
- Other
Please choose all the surgeries you have had in the past
List additional surgeries here:*
Past Hospitilizations
List Dates and Reason you were hospitalized:
Family History
Is your mother alive?
- Yes
- No
Age she passed away and reason?*
Is your father alive?
- Yes
- No
Age he passed away and reason?
Do you have any children?
- Yes
- No
How many sons?*
How many daughters?*
Are they all healthy?*
Do you have any siblings?
- Yes
- No
Do you have any brothers?
- Yes
- No
How many brothers and are they healthy?*
Do you have any sisters?
- Yes
- No
How many sisters and are they healthy?*
Social History
Do you smoke cigarettes?*
- Yes
- No
How many cigarettes per day?
- 1-5
- 5-10
- 1 pack
- 1.5 packs
- 2 packs
- more than 2 packs per day
Have you ever smoked cigarettes?*
- Yes
- No
how long ago did you quit?*
Do you drink alcohol?
- Yes
- No
How often do you drink alcohol?*
Do you use any illegal drugs?*
- Yes
- No
Which illegal drugs do you use?*
Review of Current Symptoms?
Are you CURRENTLY experiencing any symptoms that concern you?*
- Yes
- No
Pick all symptoms you are CURRENTLY having:
General
- Weight loss or gain
- Fatigue
- Fever or chills
- Weakness
- Trouble Sleeping
Ears, Nose, Throat, or Mouth Symptoms*
- Yes
- No
Which Ears, Nose, Throat, or Mouth Symptoms do you have?*
- Decreased hearing
- Tinnitus (ringing in ears)
- Earache
- Ear Drainage
- Epistaxis (Nosebleed)
- Sinus Pain
- Sore Throat
- Hoarseness
- Thrush
- Dry Mouth
- Toothache
- Pain with swallowing
- Stiffness
- Runny Nose
Respiratory Symptoms*
- Yes
- No
Which respiratory symptoms do you have?*
- Cough
- Sputum
- Wheezing
- Coughing up blood
- Shortness of breath
- Pain with breathing
- Asthma
Vascular Symptoms*
- Yes
- No
Which vascular symptoms do you have?
- Calf pain with walking
- Leg cramping
Psychiatric Symptoms*
- Yes
- No
Which psychiatric symptoms do you have?*
- Depression
- Anxiety
- Difficulty Concentrating
- Paranoia
- Sadness
- Mania
- Altered Mental Status
Cardiovascular Symptoms*
- Yes
- No
Which cardiovascular symptoms do you have?*
- Hypertension
- Hyperlipidemia
- Chest pain
- Chest tightness
- Palpitations
- Shortness of breath with activity
- Difficulty breathing lying down
- Swelling
- Sudden awakening from sleep with shortness of breath
Gastrointestinal Symptoms*
- Yes
- No
Which gastrointestinal symptoms do you have?*
- Abdominal Pain/Cramping
- Difficulty swallowing
- Heartburn/indigestion
- Change in appetite
- Black tarry stools
- Nausea/vomiting
- Diarrhea
- Vomiting blood
- Rectal bleeding
- Change in bowel habits
Genitourinary Symptoms*
- Yes
- No
which genitourinary symptoms do you have?*
- Urine frequency
- Blood in urine
- Incontinence
- Dysuria
- Nocturia
- Hematuria
- Polyuria
- Pain or burning with urination
- Difficulty with erection
- Vaginal discharge
- Vaginal pain
- Menopause
Musculoskeletal Symptoms*
- Yes
- No
Which musculoskeletal symptoms do you have?*
- Muscle or joint pain
- Stiffness
- Back pain
- Worsens with activity
- Joint swelling
- Decreased range of motion
- Arthritis
- Weakness
- Muscle Cramping
Neurological Symptoms*
- Yes
- No
Neurological*
- Change in sight, smell, hearing, or taste
- Headache
- Fainting
- Seizures
- Weakness
- Trouble with balance
- Numbness/tingling
- Tremor
- Memory loss
- Speech problems
- Fainting
Health Maintenance
Have you ever had your cholesterol levels checked?*
- Yes
- No
What year did you last have this done?*
Have you ever had a mammogram?
- Yes
- No
When was your last mammogram?*
Have you ever had a colonoscopy?
- Yes
- No
When was your last colonoscopy?*
Have you ever had a pap smear?
- Yes
- No
When was your last pap smear?*
Have you ever had your PSA checked?
- Yes
- No
When was your PSA last checked?*
Have you ever had a DEXA scan?
- Yes
- No
When was your last DEXA scan?*
Have you ever been immunized against Pneumonia?
- Yes
- No
When was your Pneumonia shot?*
Have you ever had a tetanus shot?
- Yes
- No
When was your last tetanus shot?*
Have you ever had a flu shot?
- Yes
- No
When was your last flu shot?*
Signature

We have decades of combined experience in primary care! Whether you have a cold or just need a checkup, we’re here for you!

Convenient communication, text:
Primary Care: (904) 513-3240
Pain Management: (904) 206-7132

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