Skip to content
SCHEDULE AN Appointment
(470) 395-3618
1976 Main Street E, Suite C, Snellville, GA 30078.
(470) 395-3618
Facebook-f
Twitter
Linkedin-in
Home
Meet Dr Millington
Meet The Staff
Services
Addiction Medicine
Pain Management
Auto Injury Care
Primary Medical Care
Interventional Treatment
Platelet Rich Plasma Therapy
THC Registry
Body Sculpting Treatments
Insurance & Financing
New Patient Forms
Press Release
Contact
Menu
Close
New Patient Form
Doctor in Snellville, GA
Patient Information
First name
*
Last name
*
Gender
*
Select Answer
Male
Female
Age
*
Date of birth
*
Social security #:
*
Driver's license #:
*
Street address:
*
City:
*
State:
*
Zip code:
*
Home phone:
*
Cell phone:
*
Work phone:
*
Email Address
*
Employer:
Occupation:
Guardian Information
First name
*
Last name
*
Gender
*
Select Answer
Male
Female
Age
*
Date of birth
*
Social security #:
*
Driver's license #:
*
Street address:
*
City:
*
State:
*
Zip code:
*
Home phone:
*
Cell phone:
*
Email Address
*
Work phone:
*
Employer:
Occupation:
Emergency Contact
In case of emergency who should we contact? Please provide at least one contact.
Person #1
Full name
*
Relationship:
*
Best phone:
*
Alternate phone:
*
Person #2
Full name
*
Relationship:
*
Best phone:
*
Alternate phone:
*
Person #3
Full name
*
Relationship:
*
Best phone:
*
Alternate phone:
*
Health History
Check if you have or had any of the following:
Health History
*
Anemia
Asthma
Atrial Fibrillation / Other Cardiac Arrhythmias
Bleeding Disorder
BPH (Enlarged Prostate)
CAD (Coronary Artery Disease)
CHF (Congestive Heart Failure)
COPD
CVA (Stroke)
Diabetes
Diverticulitis (Inflamed Pouches in Colon)
DJD (Degenerative Joint Disease)
Emphysema
Gallstones
GERD
Gout
Hepatitis
Hyperlipidemia
Hypertension
Hyperthyroid
Hypothyroid
Kidney Stones
Lupus
Migraines / Headaches
Pancreatitis
Peptic Ulcers
Pneumonia
Psoriasis
Pyelonephritis
UTI
Renal Disease
Rheumatoid
Seizures
TIA
Tuberculosis
Other (Describe Below)
If "other", please explain:
Surgical History (List all surgeries and dates)
Recent Tests
When did you last obtain the following tests?
Colonoscopy?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
Treadmill Stress Test?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
Lipid (cholesterol) Panel?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
PSA Test?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
Mammogram?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
Ophthalmology Evaluation?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
Podiatry Evaluation?
*
Select Answer
Yes
Never Obtained
Date:
Facility:
Lifestyle
Please answer the questions below.
Tobacco History
Have you used tobacco before?
*
Select Answer
Yes
No
Years smoked:
Packs per day:
*
Year quit:
Alcohol History
Have you used alcohol before?
*
Select Answer
Yes
No
Describe your use:
*
Select Answer
Heavy Use
Occasional Use
Rare Use
Prior Use
Year quit:
Recreational Drug Use
Have you used drugs before?
*
Select Answer
Yes
No
List drug(s) and your usage:
Current Medications
If applicable, please list the names of medications and/or supplements and how you are taking them.
Have you used drugs before?
*
Select Answer
Yes
No
Name of Medication:
Dosage:
Reason:
Name of Medication:
Dosage:
Reason:
Name of Medication:
Dosage:
Reason:
Allergies
If applicable, please list and describe your allergies.
Do you have allergies?
*
Select Answer
Yes
No
Allergy:
Medication:
Reaction:
Allergy:
Family History
Please fill in age of family member when first diagnosed. Also, list type of cancer.
Mother
Diabetes:
Coronary Disease:
Stroke:
Cancer (type):
Father
Diabetes:
Stroke:
Coronary Disease:
Cancer (type):
Brother
Diabetes:
Stroke:
Coronary Disease:
Cancer (type):
Sister
Diabetes:
Stroke:
Coronary Disease:
Cancer (type):
Current Symptoms
Put a check mark next to any symptom you are currently experiencing. If no symptoms check none.
CONSTITUTIONAL SYSTEMS:
Unexplained Weight Loss
Unexplained Weight Gain
Loss of Appetite
Fatigue
Fever
HEAD/EYES SYSTEM:
Headaches
Room spinning
Lightheaded
Visual changes
Double Vision
EARS NOSE THROAT:
Nose Bleeding
Hoarse Voice
Gum Bleeding
Ringing in ears
Trouble hearing
Neck mass
Oral lesions
RESPIRATORY SYSTEM:
Shortness of Breath
Wheezing
Coughing up blood
Chronic cough
Chronic mucus
Recurring infections
Night sweats
CARDIOVASCULAR:
Chest pain
Palpitations
Loss of consciousness
Orthopnea
Shortness of breath
Edema (swelling)
Wake up short of breath
Cold digits
Blue/White digits
Extremity sores
BREAST:
Tenderness
Swelling
Nipple discharge
GENITOURINARY (MALE):
Painful urination
Blood in urine
Increased urination
Decreased stream
Hesitancy
Urinary retention
Frequent UTI
Pelvic pain
GASTROINTESTINAL:
Painful swallowing
Reflux
Nausea
Vomiting
Vomiting blood (coffee)
Yellow Skin
Abdominal pain
Bowel changes
Flatulence
Ulcers
Irritable bowel
Hernia
MUSCULOSKELETAL:
Joint pain
Joint swelling
Joint stiffness
Muscle pain
Muscle wasting
GENITOURINARY FEMALE:
Painful urination
Blood in urine
Increased urination
Decreased stream
Hesitancy
Urinary retention
Frequent UTI
Vaginal discharge
Vaginal bleeding
Pelvic pain
ENDOCRINE:
Loss of appetite
Excess thirst
Polyuria
Polyphagia
Cold intolerance
Heat intolerance
Thyroid swelling
SKIN:
Rash
Pigmentation
Itching
NEUROLOGIC:
Numbness
Weakness
Dis-coordination
Paralysis
Tremor
Abnormal sensations
Memory loss
Headaches
ALLERGIC/IMMUNOLOGIC:
Seasonal allergies
Immune deficiency
PSYCHIATRIC:
Depression
Anxiety
Agitation
Hearing Voices
Confused
Acknowledgment
Permission to Treat & Release of Information
I give my permission for medical treatment. In compliance with state regulations and in order to facilitate optimal healthcare for you, we are required to make a reasonable effort to inform you about your lab results procedure outcomes and final x-ray reports. (The only test we may not discuss over the phone is HIV testing).
I give permission to contact me via telephone to discuss my diagnostic test results.
I authorize Mountaintop Health Care Company to release any information regarding my examination or treatment for the purpose of obtaining insurance compensation, pre-certification, or medical records.
I authorize any other medical facility to release all medical records including x-rays, laboratory results as well as any office notation that may be important for any medical treatment.
I hereby further consent to the clinic sharing information regarding me and my treatment with clinics affiliated with this clinic if I should seek medical attention or treatment at any such affiliated clinic.
Mountaintop Health Care Company’s Financial and Insurance Policy
PAYMENT & FEES
For self-pay patients, my practice operates on a fee-for-service basis. This means that your fee for each appointment will be due at the service.
Initial Appointment: (Physical Exam, Screening, Assessment, and Instructions): $150
CANCELLATIONS
When you make an appointment with me I ask that you provide me with as much notice as possible should you need to cancel or change an appointment, by calling my office phone at 470.395.3618
Cancellation 24 hours or more before appointment: No charge
Cancellation less than 24 hours before appointment: $25.00
Cancellation without notice (no-show): $50.00
The associated fee must be paid prior to rescheduling an appointment.
I have read and understood the office policy stated above and agree to accept financial responsibility described.
I have read all the information and have completed all the requested information.
I certify that this information is true and correct to the best of my knowledge.
I give permission to contact me via telephone to discuss my diagnostic test results.
A photocopy of this authorization shall be valid as the original.
Close Menu
Skip to content
Open toolbar
Accessibility Tools
Increase Text
Decrease Text
Grayscale
High Contrast
Negative Contrast
Light Background
Links Underline
Readable Font
Reset
