NEW PATIENT INFORMATION (First page) (ENGLISH)

PATIENT INFORMATION

LIVINGSTONE COMMUNITY HEALTH CLINIC
TODAY'S DATE

MonthDayYear
REFERRED BY
LAST NAME
FIRST NAME
MIDDLE NAME
Gender
BIRTHDATE

MonthDayYear
AGE
EMAIL
example@example.com
PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
Ok to Text Message
ADDRESS
CITY
STATE
ZIP
EMPLOYER
EMPLOYER ADDRESS
NAME OF SPOUSE (OR PARENT/GUARDIAN)
SS#/SIN OF PATIENT (OR SPOUSE/GUARDIAN)
SPOUSE OR GUARDIAN ADDRESS
SPOUSE OR GUARDIAN PHONE
Format: (000) 000-0000.
EMERGENCY CONTACT NAME
RELATION TO PATIENT
EMERGENCY CONTACT PHONE
Format: (000) 000-0000.
EMERGENCY CONTACT ADDRESS
SOURCE OF INCOME
If other, explain
RACE
GENDER IDENTITY
SEXUAL ORIENTATION
ETHNICITY
MARITAL STATUS
NUMBER OF FAMILY MEMBERS
FAMILY MONTHLY INCOME
FAMILY ANNUAL INCOME
DO YOU HAVE INSURANCE?
INSURANCE NAME
TOBACCO USED BY PATIENT
PATIENT EXPOSED TOBACCO?
I UNDERSTAND THAT I AM THE RESPONSIBLE PARTY AND FINANCIALLY RESPONSIBLE FOR ALL CHARGES (DEDUCTIBLES, CO-INSURANCES, ETC FOR ALL SERVICES TO ME, INCLUDING THE BALANCE REMAINING AFTER PAYMENT OF POSSIBLE INSURANCE BENEFITS.

ASSIGNMENT OF BENEFITS

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO MYSELF OR THE NAMES PROVIDED FOR PROFESSIONAL SERVICES RENDERED.
SIGNATURE
DATE

MonthDayYear
Date
I HEREBY AGREE, CONSENT AND AUTHORIZE LIVINGSTONE COMMUNITY HEALTH CLINIC ANY AND ALL PHYSICIANS, PHYSICIAN'S ASSISTANTS, NURSE PRACTITIONERS, PARAPROFESSIONALS INCLUDING MEDICAL STUDENTS, RESIDENTS, INTERNS AND/OR ITS EMPLOYEES TO ORDER OR CONDUCT ANY AND ALL MEDICAL/DENTAL/PSYCHOLOGICAL/DIAGNOSTIC/RADIOLOGICAL STUDIES, TREATMENT, DISPENSE MEDICATION OR ANY AND ALL OTHER TREATMENT, WHICH THEY CONSIDER NECESSARY AND/OR ADVISABLE FOR MY PHYSICAL, DENTAL, AND MENTAL CONDITION.
SIGNATURE
DATE

MonthDayYear
Date
Livingstone Community Health Clinic- Pediatrics Patients Intake
Birth Weight
Length(cm/in)
Pregnancy Length
Delivery Method
Complications or problems in Newborn Period:

Other
Complications or Problems During Pregnancy
Medications Taken During Pregnancy
Medical History
Type a question

Other
Surgical History
Year
Surgery type
Hospitalization
Year
Reaon
Hospital
Tuberculosis Risk Assessment

Please check one of the boxes below
Check one
Guardian's name

First NameLast Name
Guardian's Signature
Today's Date

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

Livingstone Community Health Clinic- Pediatrics Patients Intake

Medical History