Dr. Peter W. Weissgerber, MD, PA
3000 N. Orange Avenue, Suite C
Orlando, Florida 32804 USA
407-896-3091

Please complete this Patient Information Form and the OTHER TWO FORMS ONLINE and return it to Dr. Weissgerber's office. For your convenience, you may either type directly into this form and print a copy to mail or deliver, OR you may print a blank copy of the form to be completed by hand and mailed or delivered to us. To keep your information confidential and safe, we do not include an online submittal button.

After completing the form, you may then choose to mail it (see address above) or bring it to Dr. Weissgerber's office on your next visit. If you have any questions, please contact the office at 407-896-3091.

Patient Information

Last Name: First Name: MI:

Address:   
City:           State: Zip Code:
Home Phone (with area code): Work Phone (with area code):
Date of Birth:     Age: Social Security #:
Email Address:    Spouse's Name:
Driver License # Employer:

Responsible Party

Last Name: First Name: MI:

Address:   
City:           State: Zip Code:
Home Phone (with area code): Work Phone (with area code):
Date of Birth:    Age: Social Security #:
Email Address:    Spouse's Name:
Driver License # Employer:


Insurance Information (please provide insurance card for copying)
Insurance Co: Medicare #
Address:         
City:         State: Zip Code:
Phone (with area code): Insured's SS Number:
Group Name / #:
Policy Holder's Name: Relationship to Patient:

Nearest Relative Not Living in Household
Name:     Relation:
Address:
City:        State: Zip:     Phone:
Method of Payment: (Cash, Check, Mastercard, Visa)

Referred by: (check applicable box)

 Mailer
Street Sign
Phone Book 
Physician/Friend/Relative's Name:
Newsletter
Other

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Dr. Peter W. Weissgerber, MD, PA
3000 N. Orange Avenue, Suite C
Orlando, Florida 32804 USA
407-896-3091

 

Name: Date:

Our practice believes strongly in preventative health care. Please assist us by filling out this questionnaire:

Have you ever had the following: No Yes When?
Complete Physical
Cardiac Stress Test
Sigmoidoscopy (Colon cancer screen)
Dexa Scan (for osteoporosis)
Pnuemonia vaccine
Tetnus-diptheria vaccine
Cholesterol screen
WOMEN ONLY: Pap smear
                      Mammogram
MEN ONLY:     Prostate cancer screen
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