New Patient Form

This is the electronic new patient form. The same form that was already emailed to you when you initially made your appointment.
Please fill this electronic form out to your best knowledge. *If you haven’t already filled out the PDF form
If you would prefer to do this on a PDF file, you may Click Here to do so. If you fill this out on the PDF file please email it back to info@denverendocenter.com
Once you complete your Phreesia check in, you will automatically be put in queue to receive a link for ZOOM. 15-20 minutes prior to your virtual visit, you will receive a link from Phreesia to verify your identity, then you will receive your ZOOM link. Once you enter the virtual room via your ZOOM link, you will be in a waiting room for you provider. DO NOT EXIT your ZOOM waiting room, otherwise you will not be able to re-enter the ZOOM waiting room.
*IF you are Diabetic and have not uploaded your DEVICE you will be required to move your appointment to IN OFFICE or reschedule to IN office visit.*
IF you are a diabetic, it is strongly advised that you email or upload your blood sugars before seeing the provider. This will prevent your appointment from being rescheduled. (info@denverendocenter.com)

First Name and Last Name*
First Last
Best Contact Phone Number*
Email*
Drug Allergies*
Main Concernts/Reason for your visit*
Height: (Ft' In")*

Example: 5’5″ or 5 Ft 5 In
Weight (pounds)*
Medication List: Please List all medications name, Dose and how you are taking the medication.*
example: Synthroid 100 mcg 1 daily OR You may copy and paste a medication list. Please try your best to list dose and directions of your medications
Family History (health problems of your mother, father, siblings, children or grandparents ONLY)*
Example: Diabetes typ…aternal grandmother
Previous Health Problems/Hospitalizations/Surgeries/Procedures (Please include exact dates)*
Example: 01/31/2002-Thyroidectomy
Last Labs Completed (Please include eact labs dates & lab location)*
Example: Labs done 6/…/5/2020 @ Quest lab
Alcohol Use*
- Yes
- No
Number of drinks per day
DO not select if NO ALCOHOL USE
Current Smoker*
- Never Smoker
- Previous Smoker
How many cigarettes Per Day?
Do not select if NEVER SMOKER
Exercise – number of days in a week, Duration/Type of exercise:*

Example: 3 days 30 mi…ight training
Review of System: Please list current Problems/Symptoms you are experiencing now in past 1 month*
Example: Fatigue, Lum…sleep, constipation
Local Pharmacy & Phone # or address / Mail Order Pharmacy*

Example: Walgreens 10…press Scripts
Did you sign up for the Spruce Health App (for Video Visit)*
- Yes
- I need an Invitation
- No, I would like an alternative video option