We love new patients!

Welcome to Olympia Neurological Institute!

New Patient Information

Which of our clinics is nearest home?

Which one of our Doctors or Nurse Practitioners do you need to see?

Name

First Name Middle Initial Last Name

Date of Birth

What is your gender?

Female

Male

Other

Please upload copy of your driver's license or Photo ID

You may load multiple images by using the Select file button then take a picture from your phone.

E-Mail

Name of Primary Care Provider

Have you been a patient of ours before?

Yes

What is the best phone number to reach you?

Secondary Phone Number

Address

Street Address Address Line 2 City State ZIP Code

Preferred Contact Method

Text

Phone

Mail

May we sent appointment reminders via text and Voice Mail?

Yes

Are you a student?

Yes

How did you hear about our practice?

Referring Physician

Additional Patient Information

What is your Race?

What is your Ethnicity?

Hispanic

Non-Hispanic

Preferred Language?

English

Spanish

Other

Marital Status

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's First Name Spouse's Last Name

What is the name of your preferred pharmacy?

Are you currently employed?

Yes

Employer Information

Name of Employer

Employer

What is your position?

Responsible Party Information

Who is the Responsible Party?

Responsible Party's Name

Responsible Party's First Name Responsible Party's Last Name

Responsible Party's Phone Number

In Case of Emergency

Name of Emergency Contact

Emergency Contact's First Name Emergency Contact's Last Name

Phone

Relationship to Patient

Insurance Information

Please upload a front and back picture of your primary insurance card (if available)

Primary Insurance Carrier

Name of Policy Holder

Policy Holder's First Name Policy Holder's Last Name

Primary Policy Holder's Date of Birth

Primary Policy Holder's Relationship to Patient

Self

Spouse

Parent

Other

Primary Policy Contract #

Can be found on your insurance card

Primary Group #

Can be found on your insurance card

Please upload a front and back picture of your secondary insurance card (if available)

Secondary Insurance Carrier

Name of Secondary Policy Holder

Secondary Policy Holder's First Name Secondary Policy Holder's Last Name

Secondary Policy Holder's Date of Birth

Secondary Policy Holder's Relationship to Patient

Self

Spouse

Parent

Other

Allergy Information

Do you have any allergies (to Medications or Environmental)?

Yes

Are you allergic to:

Allergy Details

Basic Health History

Check if you have ever experienced any of the following:

Check if you have ever experienced any of the following II

Check if you've had any of the following tests or procedures

Colonoscopy

Cholesterol Screening

Cardiac Stress Test

Bone Density

Breast Exam

Have you had any recent CT scan(s) or MRI(s)?

Yes

Where did you have your CT Scan(s) or MRI(s) performed?

Are you vaccinated against Covid-19?

Yes

Approximate date of last Tetanus (Td) Vaccination

Approximate date of last Pneumonia Vaccination

Approximate date of last Hepatitis B Vaccination

Approximate date of last Influenza (flu) Vaccination

Approximate date of last Shingles Vaccination

Please list any additional Vaccinations you have received and the date it was administered

Please list all surgical procedures you have experienced and the date the operation was performed

Is your visit related to an accident?

Yes

Date of Accident

Type of Accident

Brief description of the accident

Are you represented by an attorney?

Yes

Attorney's Name

Attorney's First Attorney's Last

Attorney's Phone

Do you have any pins/metal plates in your body?

Yes

Please describe Pins/Metal Plates

Family Health History

Does your family have a history of Cancer?

Mother

Father

Maternal Grandparents

Paternal Grandparents

Brother

Sister

Additional Family

Does your family have a history of Diabetes?

Mother

Father

Maternal Grandparents

Paternal Grandparents

Brother

Sister

Additional Family

Does your family have a history of Heart Attack?

Mother

Father

Maternal Grandparents

Paternal Grandparents

Brother

Sister

Additional Family

Does your family have a history of High Blood Pressure?

Mother

Father

Maternal Grandparents

Paternal Grandparents

Brother

Sister

Additional Family

Does your family have a history of High Cholesterol?

Mother

Father

Maternal Grandparents

Paternal Grandparents

Brother

Sister

Additional Family

Does your family have a history of Stroke?

Mother

Father

Maternal Grandparents

Paternal Grandparents

Brother

Sister

Additional Family

If your mother is deceased, please list the primary cause and the age at her time of death.

If your father is deceased, please list the primary cause and the age at his time of death.

If your sister is deceased, please list the primary cause and the age at her time of death.

If your brother is deceased, please list the primary cause and the age at his time of death.

OB/GYN History

Date of last menstrual period

Are you currently on birth control?

Yes

Number of Pregnancies