FAMILY TREE CLINIC DEMOGRAPHIC FORM

-All information is confidential-
Name (preferred):*
Birth date:*

MonthDayYear
Date
she/herhe/himthey/themOther
Legal name/name listed on your insurance card:*
This name will be used for prescriptions, lab orders and mail. Bills will be sent to your insurance company or mailing address by this name
femalemaleno insurance
femalemalenonbinary or “X"
Social Security #
Your Phone #
yesno
yesno
Patient's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address:
Street address Apt# City State Zip
Email address:
example@example.com
YesNo
If no, please provide the name and relationship to the patient:

First NameLast Name
Relationship to patient:
Emergency contact name:
Emergency contact phone #:
languageADAnoneOther
PATIENT DEMOGRAPHIC INFORMATION - check all that apply to you
AsianBlack/African AmericanNative Americanor Alaska Nativewhitemulti-racial
Hispanic/Latino/Latina/LatinxNon-Hispanic/Latino/Latina/LatinxOther
U.S.Other
transgender (current gender is different from what was assigned at birth)cisgender (current gender matches what was assigned at birth)womanmannon-binarygender non-conforminggenderqueeragenderOther
straight/heterosexualgaylesbianbisexualqueerasexualpansexualdeclined to answerOther
INCOME AND PAYMENT INFORMATION
What is your gross MONTHLY income (before taxes)? $____________per month
enter monthly income
123456Other
RadioOther ClinicInternetBus AdHigh SchoolHotlineSex Ed classFamily/friend/partnerOther
Organization:
which one?
Event:
What event?
College:
Which college?
Rooming Policy: To provide high quality, comprehensive and confidential care, it is our policy to see each patient alone for a portion of their visit. Patients are roomed by themselves and meet alone with the clinician or patient educator at the beginning of the visit. Once this process is complete, you can request to have your companion escorted to the exam room to join you.
Patient Authorization and Consent
Research: I understand that you conduct or participate in medical research to better understand health, disease, and how care is provided. By signing below (at the end of the document), I agree that you may share my anonymous health information for research studies, unless I initial here:

Please only initial above if you DO NOT consent to research.
Quest Diagnostics: Family Tree Clinic sends labs to Quest Diagnostics. Patients may receive a separate bill from Quest.

Patient’s Right to Privacy: By signing below, I acknowledge that I have reviewed a copy of the Privacy Notice. Public copies of the Privacy Notice and Client’s Rights and Responsibilities brochure are posted in the reception area.

Consent for Treatment: By signing below, I consent to having my healthcare provider examine and treat me. I understand that this could include education, lab tests, and/or diagnostic procedures. I understand that my provider will explain the purpose of procedures and treatments and that I have the right to refuse the recommended treatment.

Income Verification: By signing below, I certify that all information regarding my income is complete and correct.

Authorization for Payment: By signing below, I give permission for my insurance carrier to pay Family Tree Clinic directly. I understand that I am responsible for payment of all co-insurance and deductibles, as well as any treatment, care and services not covered by my insurance.
Signature of patient/legal representative*
Today's Date*

MonthDayYear
Date
If Legal Representative: Name

First NameLast Name
If legal representative, relationship to patient*
Should be Empty: