Adult Patient Information

Adult Patient Information
Name

First NameMiddle InitialLast Name
Nickname
Gender
Address

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
OK to call these numbers and leave a message?
Patient Age
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact

First NameLast Name
Emergency Contact Phone
Format: (000) 000-0000.
Primary Doctor

First NameLast Name
Primary Care Clinic
Address

Street Address

Street Address Line 2

CityState

Zip Code
If you were referred, by whom?
Is this your...
Phone
Format: (000) 000-0000.
Employer
Occupation
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
OK to call this number?
Person responsible for bill

First NameLast Name
SSN
PHONE
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Information

Must be completed in addition to obtaining a copy of your card
Primary Insurance
Policyholder's Name
Secondary Insurance
Policyholder's Name
Assignment of Benefits: I hereby assign to the physician all payments for medical services rendered to my dependents. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all the charges whether or not paid by insurance. I hereby authorize said assignee to release all information necessary to secure payment.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Adult Patient Information

Insurance Information