Patient Registration Form

Please complete the Patient Registration Form carefully and completely. The information you provide on the form will directly influence your care at AZ Max. We assure you that all information you provide will be kept completely confidential. Please alert AZ Max to any existing medical conditions (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) you may have and disclose all medications (i.e. heart medications, aspirin, blood thinners, etc.) to your doctor at the time of your consultation.

Technical Note: *Once reviewed, scroll down to register.

Mac Users
CLICK HERE TO REVIEW STEP-BY-STEP INSTRUCTIONS

PC Users
Our online form uses the latest Adobe Acrobat Reader plug-in to conveniently submit the form from home or work. Please download the free plug-in from Adobe's web site if it is not already installed on your system. It is important that you have at the latest version of the plug-in to successfully use our online form.