EZMEDICAL Medical Registration

Please enter your information accurately.

Today's Date:

Patient Name:
Date of Birth:
Social Security Number:
Address:
City, State & Zip Code:
Email:
Phone Number:
Symptoms Description:
Health History:	Chicken Pox Measles Covid-19 Small Pox Tetanus
Gender:	Male Female Other
Vaccination Status:	Yes No
Are you covered by insurance?	Yes No
Substance Use History:	Yes No
Desired User ID:
Password:
Re-enter Password:
Health Rating (1-10):	5