1 Patient Demographics Intake and Annual Update

  • Patient Demographics Intake and Annual Update

  • PLEASE RETURN YOUR NEW PATIENT FORMS TO US BEFORE YOUR FIRST APPOINTMENT

  • Patient Information

  • Date of Birth:*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: 000-00-0000.
  • Gender:*

  • Relationship Status:

  • Divorced for years.
    Married for years.
    Separated for years.
    Single for years.
    Widowed for years.

  • Race (Check as many as apply) :
  • Language (Check as many as apply):

  • Communicating With You

  • How do you prefer to receive appointment reminder notifications?*

  • You agree and acknowledge that email, calls, texts, voicemail and any form of messaging to your home, mobile, work or other contact will pertain to information regarding things like appointments, patient portal, test results, medication side effects and prescriptions. If you wish to extend communication regarding your specific medical treatment and share of information with others, we ask that you sign a Release of Information form. If this information should at any time need to be modified, please complete a new Patient Demographic Form and/or ROI form with your requested change(s). If you wish to opt-out of any form of communication, please specify.

  • Type of information that may be sent:

  • Note: If you wish to grant medical release of information (ROI) you must complete the ROI form.

  • Referral and PCP Information

  • Pharmacy and Prescription Plan

  • Please tell us which local pharmacy and mail order pharmacy that you use to fill your prescriptions:

  • Local Pharmacy:

  • Local Pharmacy:
    Name: Store #: Phone #:
    Address:

  • Mail Order Pharmacy:
  • What company provides your prescription coverage? Check one option below:

  • Rx ID#:
    Rx Group #:
    Rx Bin:
    Rx PCN:

  • Insurance / Financial Responsibility

  • Primary Payer:*

  • ↑↑↑ (CHECK ONE BOX ABOVE FOR YOUR INSURANCE PAYER NAME or CHECK ‘SELF PAY’ BOX IF NO INSURANCE) ↑↑↑

  • Subscriber's Date of Birth:*
     / /
  • Format: 000-00-0000.

  • Secondary/Supplemental Insurance Payer:
    (Complete this section only if you have a secondary payer or supplement plan)

  • [Important Notice: We do not accept Florida Medicaid, out-of-state Medicaid plans or any Medicaid HMO plans]
  • Should be Empty: