Professional Excellence

in Internal Medicine & General Procedures

Dr Zock’s clinic provides innovative, hands on solutions to eliminate general health problems and solving complex diagnoses. The clinic combines years of experience and new technologies.

New Patient Information

Registration with iHealth Clinics

Step 1 of 10

First Name*
First
Last Name
Last
Address
Email
Driver License Number*
Biological Gender*
Gender Identity (optional)
Date of Birth*
Social Security Number*
Email
Primary phone Number*
Alternate Phone Number
Preferred
Race Categories*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian
- White
- Would rather not share
THIS IS REQUIRED FOR MEDICARE MEANINGFUL USE
Ethnicity Categories.
- Hispanic or Latino
- Not Hispanic or Latino
Pharmacy Information and Phone Number*

Do you have any allergies?*
List your allergies*

Medications
Do you take any medications?*
List your Medications (Over the counter, Prescriptions and Birth Control)*
Name and Dosage How often do you take it Daily?
Are you missing a few?
- Yes
- No
That's OK. We will check with the pharmacy.

Screening Section
Last Menstral period
MM slash DD slash YYYY
Last Menstral Period
Pregnancy Total (Gravida)
Total # of Pregnancies
Pregnancy Deliveries (Para)
Term, Preterm, Abortions (spontaneous or induced) and Living
Recent Colonoscopy
Recent Colonoscopy
Recent Mammogram
Recent Mammogram
Recent DEXA (Bone Density)
Recent DEXA (Bone Density)
Recent Pap Smear
Recent Pap Smear

Surgical History
Have you had any surgeries?
Please list all prior surgeries and approximate dates performed (use the add button)
Surgery Approximate Date

Do you see any other Medical Provider regularly?*
List other medical providers you see on a regular basis
Doctors Name Office Phone Other Contact Information

i.e cardiologist, mental health provider, kidney doctor, dentist etc.
Consent
I authorize Ihealth Clinics to Request my Protected Health Information from other Medical Entities
Specific Information that should be disclosed
- Last 24 months office notes/labs/x-ray
- Last 12 months office notes/labs/x-ray
The purpose of this disclose is
- Primary Care Health Records
The authorization will expire on the following date:
Leave Blank If unsure, or No expiration as long as there is patient-doctor relationship.
Are you the patient or a personal Representative?*
Name of Personal Representative*
First Last

PROTECTED HEALTH INFORMATION RELEASE
To whom may we disclose your protected health information?
List authorized members of your circle
Name Relationship Contact #

Patient Demographics

Step 1 (Start here). Based on your medical history, this might take longer than usual. Due to HIPAA rules, you cannot save and continue later.

Identification Card Upload

Take a front and back picture of your ID card and/or Insurance if applicable and upload.

Pharmacy Information and Address

Where we will send your prescription and refills.

Opioid Medication for Cronic Pain Agreement

Where we will send your prescription and refills.

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Professional Excellence

in Internal Medicine & General Procedures

New Patient Information

Step 1 of 10

Medications

PERSONAL MEDICAL HISTORY

Screening Section

Surgical History

Social History (check all that apply)

Family History

PROTECTED HEALTH INFORMATION RELEASE

Patient Demographics

Identification Card Upload

Pharmacy Information and Address

Opioid Medication for Cronic Pain Agreement

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iHealth Clinics. 20923 Kingsland Boulevard, Katy, TX, 77450. Copyright © 2024

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Name (or Organ: Colon, Prostate, Brain)	Approximate Age of diagnoses

Name and Dosage	How often do you take it Daily?

Admitting Diagnoses	Date

Medical Problem	Duration of aforementioned Medical problem

Surgery	Approximate Date