New Patient Registration

Please complete this form so our office has accurate registration, communication, and health information. You can review your answers before submitting.

Privacy acknowledgment
We protect the privacy of your health information and use or disclose it as permitted by law for treatment, payment, and healthcare operations. You may review the practice's Notice of Privacy Practices for more information about how your health information is handled and your privacy rights.

Legal first name

Legal last name

Preferred name

Date of birth

Date of service

Sex

Please specify

Contact Information

Home address

City

State / ZIP

Primary phone

Mobile phone

Email address

Preferred language

Marital status

Race / ethnicity (optional) Employer / occupation

Pharmacy & Emergency Contact

Preferred Pharmacy

Pharmacy name

Phone

Location

Emergency Contact

Name

Relationship

Phone

Responsible Party & Insurance

Is someone other than you financially responsible for your medical care?

NoYes

Name

Relationship

Date of birth

Phone

Address

Primary Insurance

Insurance plan

Subscriber name

Subscriber DOB

Subscriber ID

Group number

Do you have secondary insurance?

NoYes

Secondary insurance plan

Subscriber name

Subscriber DOB

Subscriber ID

Group number

Medical Care & Financial Responsibility

I voluntarily consent to evaluation, treatment, and routine medical services provided by Kyaw Lyn, MD, and authorized clinical staff. I understand that I may ask questions about my care and may refuse treatment.

I authorize release of information necessary for treatment, payment, and healthcare operations, including submission of claims to my health insurance plan. I understand that I am financially responsible for applicable copayments, deductibles, coinsurance, noncovered services, and balances not paid by my health insurance plan.

Signature

Please sign below. This signature can be reused for later consent sections if you choose.

Notice of Privacy Practices

The practice protects the privacy of your health information in accordance with applicable privacy laws. The Notice of Privacy Practices explains how your health information may be used or disclosed for treatment, payment, healthcare operations, and other purposes permitted or required by law, and describes your rights regarding your health information.

I received a copyI declined a copy

Privacy Practices Acknowledgment

Use my previously provided signature

Privacy & Communication

Would you like to authorize us to discuss your health information with another person?

NoYes

Name

Relationship

Phone

Information allowed

All informationLimited information

Please specify

+ Add another authorized person

How may we contact you?

Authorization Signature

Use my previously provided signature

Telehealth Consent

Telehealth may include medical visits by secure video, telephone, or other electronic communication when you and the clinician are in different locations. Telehealth may have limitations compared with an in-office visit, including the inability to perform a complete physical examination. You may decline or stop telehealth and request an in-person visit when clinically appropriate.

Telehealth Consent Signature

Use my previously provided signature

AI Scribe Consent

Our office may use a HIPAA-compliant AI scribe to assist with documenting your visit. The AI scribe is used to help your provider create a draft medical note. This allows your provider to spend less time typing and more time focused on your care. The service is used in accordance with applicable privacy and security requirements for protected health information.

Your choice is voluntary. Signing this consent is not binding and you have the option to request that it not be used for any particular visit, or change your mind at any time. Declining AI Scribe will not affect your ability to receive medical care from this office.

AI Scribe Consent Signature

Use my previously provided signature

Past Medical History

Select all conditions you have now or have had in the past.

Please specify other condition(s)

Mockup shortened visually. The production form will include the complete PMH list from the approved paper packet.

Surgeries & Hospitalizations

Have you ever had surgery, a procedure, or been hospitalized?

NoYes

Surgery / procedure / hospitalization

Approximate date

Hospital / location

+ Add another

Current Medications

Do you currently take prescription medications, over-the-counter medications, vitamins, supplements, or herbal products?

NoYes

Medication / supplement

Dose

How often?

Reason

+ Add another medication

Allergies

For each Yes: allergen / medication → reaction → severity → + Add another.

Family History

Please enter significant health conditions in your biological family. “Unknown” is available.

Mother

Significant medical conditions

Father

Significant medical conditions

Siblings

Significant medical conditions

Children

Significant medical conditions

Social History

Tobacco / nicotine use

NeverFormerCurrent

Type

Amount / years

Alcohol use

NoneOccasionalDaily

Recreational drug use

NoYes

Please specify

Exercise Dietary restrictions or special diet Living situation

Medical Records Authorization

This authorization allows Kyaw Lyn, MD, Inc. to obtain or provide the medical records you select for the purpose you specify.

I do not wish to authorize obtaining or releasing medical records at this time.

What would you like us to do?

Obtain records from another provider/facility Send records to another provider/facility

Doctor / Facility

Phone

Address

City / State / ZIP

Fax

Records Requested

Please specify

Purpose

Continuity of carePersonal useInsuranceOther

Please specify

This authorization expires one year from the date signed unless you enter an earlier expiration date.

Earlier expiration date (optional)

Medical Records Authorization Signature

Use my previously provided signature

Review Your Answers

Please review your information. Nothing is marked as “good” or “bad.” Use Back to make changes.

PatientJane Sample · 01/01/1950

Preferred PharmacySample Pharmacy

Primary InsuranceSample Health Plan

TelehealthI consent

AI ScribeI consent

Past Medical HistoryHigh blood pressure; High cholesterol

MedicationsExample medication · once daily

AllergiesNone known

Patient attestation
Moving forward to submit this questionnaire means you attest that the information you provided is true and complete to the best of your knowledge.

Final Certification Signature

Use my previously provided signature

Questionnaire Complete

Please hand this tablet back to the front desk. Do not click any further buttons.

Staff use only

Staff PIN → Generate / Save PDF → verify upload to chart → confirm upload → Clear Patient & Start New Patient.