New patient Form – Iker Leycegui M.D.

Please fill in as much information as possible to expedite your visit scheduling. Any further details can be discussed in person

First Name *

Last Name *

Your Email *

Date of Birth

Address

Street, City, Zip Code, State, Country

Sex

Last primary care physician / provider name

How did you find Dr. Leycegui

Current issues – symptoms you would like to discuss in your initial visit

Expand as much as you'd like.

Past medical history - Continued : Diagnosis/Surgeries/ Hospitalizations (Add especially if not above))

Medication Allergies *

Only to Medication's, do not include environmental, food allergies in this section. if none type None.

Occupation: if retired past occupation. Any exposure to dangerous chemicals/ compounds in the present or past? *

Alcohol - Drinks per week on average

Exercise: 30 minute or more- sessions per week

Coffee Cups / Shots per day

Selected Value: 0

Recreational Drugs

Leave blank, if none

Tobacco Smoking Status

If smoker have you had a CT scan of the chest for lung cancer screening?

If yes, approximate date, and did you have any pulmonary nodules?

Colonoscopy

If you had a Colonoscopy - please provide approximate date of last one.

When was your last mammogram? (Approximate date if unsure)

When was your last Pap smear? (Approximate date if unsure)

Do you have a GYN? if you do, please type name

Date of last Bone density test? if never or unknown leave blank

Date of last PSA test? if never or unknown leave blank

If you had a cardiac catheterization, please type approximate date

If you had a stress test, please type approximate date

Have you had a tetanus vaccination in the past five years?

Have you had an influenza vaccination in the past year?

Have you had a pneumonia vaccination in the past five years?

Have you ever had that tuberculosis vaccine BCG?

Have you ever had the COVID-19 vaccine / boosters ?

Current medication's

Please list your current medications. If the list is extensive, you may attach the list or bring your medications or their list to your appointment.

Primary Phone Number for Contact *

Emergency contact name

Emergency contact phone number

We communicate via email, text messages, and voice calls. Do we have your permission to contact you through these methods? *

While we do not accept insurance, we still require insurance information to electronically send bloodwork, radiology, and other tests. Please provide the details below. Alternatively, you can furnish this information during your visit

Patient Policy Agreement : Welcome, we are committed to providing comprehensive, patient-centered care with a focus on thorough evaluations, transparent communication, and personalized medical treatment. To ensure a smooth and professional experience, please review and acknowledge the following policies before your first appointment. 1. Payment & Fees I understand that Iker Leycegui M.D. is an independent medical practice and does not bill insurance directly. Payment is required at the time of service. If laboratory tests, imaging, or specialist referrals are ordered, I understand that these services may be billed separately by third-party providers. I acknowledge that my doctor will discuss testing options and costs with me before proceeding, and I will have the opportunity to accept or decline recommended testing. 2. Medical Approach & Responsibility I understand that my provider follows evidence-based medical practices and takes a comprehensive, proactive approach to healthcare. I acknowledge that healthcare is a shared responsibility between doctor and patient. I agree to follow the recommended plan of care, including scheduling follow-ups as advised. If I choose not to follow medical recommendations (such as declining diagnostic tests, referrals, or treatments), I understand that this may impact my health and medical outcomes. 3. Professionalism & Communication I agree to communicate respectfully with my provider and office staff. I understand that disruptive, disrespectful, or inappropriate behavior may result in termination of care from the practice. If I have concerns about my care, I will address them directly with the office rather than posting complaints online or on social media. 4. Cancellation & No-Show Policy I understand that appointment slots are reserved for me, and I agree to provide at least 24 hours’ notice if I need to reschedule or cancel. Repeated no-shows or last-minute cancellations may result in fees or dismissal from the practice. 5. Termination of Care I understand that my provider reserves the right to discontinue care if there is: A breakdown in communication Non-compliance with medical recommendations Disruptive or inappropriate behavior If my provider determines that our medical relationship is not beneficial, I may be referred to another provider for continued care. 6. Agreement & Acknowledgment By signing below, I confirm that I have read, understood, and agree to the policies outlined above. *

I have read, understood, and agree to the Patient Policy Agreement.

Signature *

Type First and Last Name

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