Patient Center

Name: Lighthouse Medical Center
Address: 4 Northeast 4th Avenue, Pompano Beach, FL, 33060, US
Telephone: (754) 222-6642
Price range: $

Welcome to Lighthouse Medical Center! As a new patient, you can save time and streamline your visit by completing our easy online form before you arrive. This will help us get to know you better and ensure we provide the best care possible.

Thank you, and we look forward to meeting you!

Your Information

Have You Visited Lighthouse Medical Center Before?

I'm a New Patient

Yes, I Have

First Name *

Last Name *

Address

Street Address

City

State

Country

Postal code

Email *

Phone *

Date of birth

Occupation

Employer

Marital Status

How Did You Hear About Us?

Emergency Contact

Emergency Conatct Full Name

Relationship

Phone Number

Your Insurance

Primary Insurance Company

Subscriber Name

Plan

Past Medical History

Have you ever had:

Are You Currently On Any Medications?

Yes, I am

No, I am not

If you answered yes, please lest all medications (Name, Dosage, Frequency) OR Upload Image of Labels Below

Prescription Label Upload

Take a Picture of Medication Label

Do You Have Allergies?

Yes, I do

No, I do not

If yes, please include all allergens (Medications, Foods, Seasonal)

Surgical History:

Family History:

Do you have either/both of the following:

Pacemaker

Defibrillator

Do you smoke?

Yes, I do

No, I do not

If you smoke, how many cigarettes per day and how many years have you been smoking?

Do you consume alcohol?

Yes, I do

No, I do not

If you drink, how many drinks per day/week?

Body Systems Review

Constitutional Symptoms

Eyes/Vision

Ears Nose Mouth & Throat

Cardiovascular System

Gastrointestinal System

Psychiatric Health

Neurological System

Genitourinary System

Intergumentary System & Breast Health

Endocrine System

Hematologic & Lymphatic System

Lighthouse Medical Center Experts in Chiropractic and Holistic Care in Pompano Beach, FL.

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(754) 222-6642Click To Call Us Now

Office Hours

Monday 8 am-6 pm

Tuesday 8 am-6 pm

Wednesday 8 am-12 pm

Thursday 9 am-6 pm

Friday 8 am-12 pm

Sat-Sun (Closed)

Schedule Now

4 NE 4th Ave, Pompano Beach, FL 33060, USA

HEALTHCARE DISCLAIMER

HIPAA POLICY

ACCESSIBILITY

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