PATIENT DEMOGRAPHIC FORM

FAMILY HEALING CENTER
DEMOGRAPHIC FORM
Name (Last, First, MI)
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Marital Status

SingleMarriedWidowedDivorcedSeparatedOther
Race
Ethnicity
Date of Birth

MonthDayYear
Date
Preferred Language
Email Address
example@example.com
Primary Insurance Company
Policy #
Group #
Patient's Relationship to Insured

SelfSpouseChildOther
Name of Subscriber (if other than patient). Last, First
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Employer of Subscriber
Secondary Insurance Company
Policy #
Group #
Patient's Relationship to Insured

SelfSpouseChildOther
Gender

FemaleMale
Date of Birth

MonthDayYear
Date
Employer of Subscriber
Full Name
Relationship
Emergency Contact Information
Name
Relationship to Patient
Home Number
Work Number
Cell Number
By signed below, I acknowledge that the information I provided is correct to the best of my ability. I authorize release of any information necessary to process my insurance claims and assign and request payment directly to my Therapist.
Patient Signature
Date

MonthDayYear
Date
Guarantor Signature: (Other than patient
Guarantor Signature
Date

MonthDayYear
Date
For Office Use Only Therapist:
Therapist
Should be Empty:

DEMOGRAPHIC FORM