Patient Release Form

Patient Release Form
Patient Name*

First NameMiddle NameLast Name
Responsible Party/Guardian

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email *
example@example.com
Birth Date*

MonthDayYear
Sex*

MaleFemale
Marital Status*

SingleMarriedWidowedDivorced
Social Security Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Primary Language*

EnglishSpanishOther
Ethnicity

Non-specifiedNon-Hispanic or Non-LatinoHispanic or LatinoOther
Race

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or other Pacific Islander
Primary Care Physician*
Date of last visit to Primary Care Physician*

MonthDayYear
Date
Name of Preferred Pharmacy*
Address of Preferred Pharmacy*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*

TVFriend or Family MemberYour doctor referred youInternet (Google, Facebook, etc.)Other
What is the name of the doctor who referred you?*

PrefixFirst NameLast Name
What is the name of the friend or family member who referred you?*

First NameLast Name
Are you employed?

YesNo
What is your occupation?
If unemployed, type "NA"
Where are you employed?
What is your phone number at work?
Please enter a valid phone number.
Primary Insurance*
Policy Number*
Policy Holder

First NameMiddle NameLast Name
Who is the primary policy holder?*

SelfSpouseChildOther
Do you have a second form of insurance?*

YesNo
Secondary Insurance
Secondary Insurance Policy Number
Secondary Insurance Policy Holder Name

First NameMiddle NameLast Name
Secondary Insurance Policy Holder Relationship to Patient

SelfSpouseChildOther
Is this a workers compensation case?

YesNo
What is the claim number?
Who is the case manager?

First NameLast Name
What is the case manager's phone number?
Please enter a valid phone number.
Should be Empty: