PATIENT INFORMATION FORM

PATIENT INFORMATION: (Please Circle) Minor Single Married Divorced Widowed

Last Name:_____________________________ First:__________________________ M.I.___________ Sex: M/F

Social Security #__________________________ Date of Birth: _________________________ Age:___________

Address:_______________________________ City:_______________________ State:_______Zip:____________

Home # ________________________ Cell #________________________ Work #__________________________

POLICY HOLDER INFORMATION: (Please Circle) Single Married Divorced Widowed Separated

Last Name:_____________________________ First:__________________________ M.I.____________ Sex: M/F

Social Security #______________________ Date of Birth:_______________ Driver’s License #_______________

Address:_____________________________________Home #:____________________Cell #:________________

(if different from above)

Name of Employer:_________________________________________Phone:______________________________

SPOUSE INFORMATION:

Last Name:____________________________First:___________________________M.I.____________Sex: M/F

Social Security #:_______________________ Date of Birth:________________Driver’s License #:_____________

Address:_____________________________________ Home#_____________________Cell #:________________

(if different from above)

Name of Employer:_________________________________________Phone:______________________________

GENERAL INFORMATION:

Family Physician Name:________________________________________Phone:___________________________

Nearest Relative(not living with you) _________________________________Phone:___________________________

Incase of Emergency Notify:_________________________Phone_________________Relationship:____________

INSURANCE INFORMATION:

Who referred you to our office? (Doctor/Friend/Phonebook)______________________________Phone:______________

Primary Insurance Plan:________________________________Policy Holder’s Name:_______________________ ID#:____________________________Group#_____________________Phone:____________________________

Secondary Insurance Plan:______________________________Policy Holder’s Name:_______________________

ID#:____________________________Group#:_____________________Phone:____________________________

HIPAA INFORMATION: Instructions for the office when returning phone calls or reminding you about appointments.

I authorized the office to contact me at: [ ] Home [ ] Work [ ] Cell and May leave messages at: [ ] Home [ ] Work [ ] Cell.

I authorize the office to leave detailed messages about appointments/phone calls: [ ] YES [ ] NO

If you prefer us to leave messages with a specific individual please list them below:

1.__________________________ 2._________________________ 3.___________________________

INDICATE ANY SPECIAL REQUESTS, IF ANY:_________________________________________

Patient (or Parent/Guardian) Signature:_____________________________________________Date:_____________