Phoenician Cardiology - Patient Intake Form

Patient Demographics

First Name

Middle Name

Last Name

Date of Birth

Gender

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Cell Phone

Employer

Occupation

Work #

Marital Status

Preferred Language

Race

Ethnicity

Emergency Contact

In case of an emergency, please notify:

Name

Relationship

Phone #

Alt Phone #

Physician & Pharmacy Information

Primary Care Provider

Phone #

Referring Provider (if different)

Referring Provider Phone #

Pharmacy Name

Pharmacy Phone #

Pharmacy Location Cross Streets

Pharmacy City and Zip Code

How did you hear about us?

Benefit Assignment

I hereby authorize the staff of Phoenician Cardiology (PC) to provide medical services, either regular or emergency, as determined by my physician to be in my best interest (or the interests of any dependant) if I am signing as a guardian or medical power of attorney.

I authorize payment of medical benefits to Phoenician Cardiology. I agree all charges for medical services rendered that are not directly paid by my insurance will be my responsibility. I hereby authorize Phoenician Cardiology to release the necessary information regarding my healthcare to my healthcare plan to process and complete my insurance claims.

Patient/Responsible Party Signature

Date

Primary Insurance Information

Insurance Company

Group #

Policy #

Insurance Phone #

Insurance Address

Policy Holder Name

Policy Holder DOB

Policy Holder

Employer Name

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insurance Information

Insurance Company

Group #

Insurance Address

Policy Holder

Employer Name

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Responsible Party Information

Name of Responsible Party

Date of Birth

Phone #

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Name

Employer Address

Employer Phone #

If Workers Compensation, please provide the following information.

Claim #

Adjusters First & Last Name

Adjusters Phone #

Company Name

Medical History

Patient Name

DOB

Reason for today's visit?

Medications

Name of Medication

Strength per pill