Synergy Family Medicine Patient Registration

We provide three options for you to register your information:

Option A: (Preferred option)

Fill out the following two forms online and submit to us online.

1. Please click here to fill out the online patient demographic information form.
2. Please click here to fill out the general health information intake form.

All your registration and general health information will be transmitted securely and confidentially by SSL.

Instant SSL Certificate
DV SSL Certificate Seal

When you access the registration form for the first time from your computer, you internet browser may send you a warning like “ Connection untrusted” and ask you “Do you want to proceed?” or “make an exception”. This is a routine question the browser usually would ask when you submit information to a SSL secure website new to your computer . Please click “Yes-to proceed” and “make exception” to proceed to the registration forms. You should not receive the warning again when you use the same computer to access the same web site later.

Option B:

Please click here to download and print the entire registration form. Kindly bring the completed form to your first appointment at our clinic.

Option C:

Please arrive 15 minutes before your scheduled first appointment and complete the registration forms in the waiting room.

Please read the following information before you request the release of your medical record.

Please be aware that some medical offices may charge a fee for releasing any medical record. In order to keep the cost modest, you may consider to request only the latest and most pertinent information.For most pateints, the medical problem/medication summary page, the most recent complete physical exam and the most recent one year of lab and radiology report would be enough. If you wish to transfer your medical record to Synergy Family Medicine, please feel free to print this Medical Record Release Form.

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