Patient Demographics

Patient's Legal Name

Birthday

Month

Day

Year

Social Security Number

Birth Gender

Male

Female

Preferred Name & or Pronouns

Employment Status

Patient's Marital Status

Marital Status

Patient Contact Information

Physical Address

Is you mailing address different from your physical address?

Yes

Home Phone

Work Phone

Cell Phone

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship to patient:

Emergency Contact Phone #

Insurance Information

Primary Insurance

Subscriber name, date of birth, social security #, and phone #

Secondary Insurance

Subscriber name, date of birth, social security #, and phone #

Patient Care Team Information

Referring Provider

Primary Care Provider

Other Physicians on your care team:

By signing below, I authorize this office to release any information necessary to expedite payment. Protected health information may be disclosed to another covered entity for select health care operation such as payment activities, treatment, quality assessment activities, and other purposes. I have signed a copy of the Office Policy and been offered a copy of the Notice of Privacy Practices. I understand the organized health care arrangement has the right to change this notice at any time and that I may obtain a current copy by contacting the office. Regardless of insurance coverage I also understand that I am ultimately responsible for all charges, including attorney’s fees and collection costs.

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