Patient Demographic Form

1
Which best describes you?* This field is required.
I am the patient
I am completing this for the patient
2
Your Name
First Name
Last Name
3
Your relationship to the patient
Spouse
Other Family Memeber
Caretaker
Personal Assistant
Other
4
Your Email
example@example.com
5
Your Phone Number
Please enter a valid phone number.
6
Patient's Name* This field is required.
First Name
Last Name
7
Patient First Name* This field is required.
8
Patient Last Name* This field is required.
9
Patient Mobile Phone
Please enter a valid phone number.
10
Patient Email* This field is required.
example@example.com
11
Race (from the NIH Racial and Ethnic Categories)* This field is required.
White
Black or African American
Hispanic or Latino
Asian
Native Hawaiian or Pacific Islander
Indigenous American or Alaska Native
12
Date of Birth* This field is required.
Year
Month
Day
13
SexAssigned at Birth
Male
Female
14
Gender* This field is required.
Male
Female
Other
15
Patient Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Country* This field is required.
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
17
Patient's Social Security Number (Confidentiality Ensured)* This field is required.Because no unique personal healthcare identifier has been established in the United States, providers have defaulted to the Social Security number (SSN) as a unique identifier. SSN has become universally identified as the single most powerful identifier in use in the United States. As with the remainder of your health record, its privacy and security are mandated by federal standards and we restrict access by limiting use to only those who have a job-related need to access it and displaying only the last four digits to all others.
Do NOT include hyphens (-)
18
Patient's Passport Number (Confidentiality Ensured)* This field is required.Because no universal personal healthcare identifier has been established, providers have defaulted to using PASSPORT number as an international identifier. As with the remainder of your health record, its privacy and security are mandated by federal standards and we restrict access by limiting use to only those who have a job-related need to access it and displaying only the last four digits to all others.
19
Emergency Contact* This field is required.By providing this information you agree to allow us to communicate with this individual about your health in the event of an emergency.
First Name
Last Name
20
Relationship of Emergency Contact* This field is required.
Spouse
Family Member
Significant Other
Friend
Doctor
Caretaker
21
Emergency Contact Mobile Number* This field is required.
Please enter a valid phone number.
22
Do you require a translator to understand basic English?* This field is required.
Yes
No
23
Primary Language
French
Spanish
Portugese
Italian
Mandarin
Hindi
Arabic
Other
24
What describes the way you heard about Dr. Antonucci?
Past/Current Patient
Friends/Family Member
Carrick Institute
Google Search Result
Social Media (Facebook, Instagram, LinkedIn, etc)
A Medical Professional
An employee of Dr. Antonucci
Event/Outreach/Conference
Media (TV, Magazines, etc)
Other
25
Referral InformationWe would like to contact them and thank them for referring a patient. Your identity will not be revealed
First Name
Last Name
Suffix
26
Communication Method Currently, the only secure method to transmit health information is through facsimile ("fax"). If you would like to use a form of communication OTHER than fax, you acknowledge the possibility of unintentional disclosure of your protected health information. If you choose an alternative method of transmission, in the event of such a disclosure, you agree to hold NeuroSynergy Associates harmless.* This field is required.
Fascimile ("Fax")
Email
Text Message (SMS/MMS)
What's App
Patient Portal (When Available)
27
Authorized Communications* This field is required.You are authorizing us to share the following information by the electronic means
Appointment Reminders
Supplement/Prescription Reminders
Medical Concerns
Communications
Other
28
Photo of Government Issued Identification* This field is required.Please upload your Passport or Drivers License (Guardian's if Under 18). This is used to confirm the identity of the patient/their responsible party
Should be Empty: