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Eileen C. Comia, M.D. (Advance Biomedical Treatment Center)

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Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
Tel (860)242-2200
Fax (860)242-2212
info@advbiomedtx.com
Please print legibly. All information will be kept confidential.
ABTC Reg Form 0119
Page 1 of 2
Today’s Date: ______________
Last Name: ______________________________ First Name: _________________________ MI: ___
Birthdate: ____________________ Age: ____ M / F: ___ Social Security no. ____________________
Street Address: _____________________________________________________ Apt no. ___________
City __________________________________________ State _______ Zip ______________
Country __________________________________ Email: _____________________________________
Home: (_____) ________________ Cell: (_____) ________________
PARENTS INFO (If patient is a minor, please complete.)
Father’s Name: _________________________________________ Tel (____) ____________________
Address: ____________________________________________________________________________
Occupation: _________________________________________________________________________
Mother’s Name: ________________________________________ Tel (____) _____________________
Address: ____________________________________________________________________________
Occupation: _________________________________________________________________________
EMERGENCY CONTACT (Other than the Parent)
Name: _____________________________________________ Relation to Patient: ________________
Tel: (____) ___________________________ Email: __________________________________________
PATIENT INFO
Diagnosis / Date Diagnosed: _____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Medications: ________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Eileen C. Comia, M.D.
35 Jolley Drive Suite 102
Bloomfield CT 06002
Tel (860)242-2200
Fax (860)242-2212
info@advbiomedtx.com
Please print legibly. All information will be kept confidential.
ABTC Reg Form 0119
Page 2 of 2
Allergies: Foods: _____________________________________________________________________
Medications: ________________________________________________________________
Environmental: ______________________________________________________________
Chemical: ___________________________________________________________________
Others: _____________________________________________________________________
Primary Care Physician: _______________________________________ Tel (_____) ______________
Address: ____________________________________________________________________________________________
I certify that the information on this form is true to the best of my knowledge. I accept responsibility for
the medical charges incurred and agree to pay all bills at the time of service.
______________________________________________
Patient Printed Name
______________________________________________ ____________________
Patient Signature Date
(Parent/Legal Guardian if patient is a minor)
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Eileen C. Comia, M.D. (Advance Biomedical Treatment Center)

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Completed 25 May 2021

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