Northbridge Family Medicine
New Patient Intake

New patient registration

Please complete this form before your first visit so our care team has an accurate picture of your health. All information is protected and confidential.

Patient information
Daniel Okafor
08 / 19 / 1985
[email protected]
(555) 442-0917
418 Larkspur Ave, Apt 3B, Northbridge, OH 44012
Insurance
BlueShield PPO
BS-49102283
GRP-7740
Larkin Drug, 9th & Main
Medical history
Type 2 diabetes (2019), appendectomy (2011). Father — heart disease; mother — hypertension.
Penicillin, shellfish
Annual physical
Current medications
Medication
Dose
How often
Metformin
500 mg
Twice daily
Lisinopril
10 mg
Once daily
Vitamin D3
2000 IU
Once daily

Leave blank if none. Include over-the-counter and supplements.

Consent to treatment

I consent to medical evaluation and treatment by the providers of Northbridge Family Medicine. I certify that the information I have provided is accurate to the best of my knowledge, and I acknowledge that I have received and understand the practice's Notice of Privacy Practices (HIPAA).

Daniel Okafor
Patient (or guardian) signature
June 17, 2026
Date

Northbridge Family Medicine · Information collected here is protected under HIPAA.