New Patient Information Form

Last Name:

First Name:

Middle

Date of Birth:

Gender:

Insurance ID #:

ETHNICITY:

Hispanic/Latino Non-Hispanic/Latino Unknown

RACE:

American Indian/Alaskan Native Native Hawaiian/Pacific Islander Asian White Black/African American Other

If other, please specify:

MOTHER:

Last Name:

First Name:

Middle

Date of Birth:

Is this a Step-Parent

Yes No

Home Address

City

State

Zip Code

Home Phone No.

Cell Phone No.

Email address

Preferred Language:

Add Parent or Legal Guardian

EMERGENCY CONTACT:

Emergency Contact Name:

Relationship:

Phone #:

PRIMARY INSURANCE COMPANY

Insurance Company Name:

Phone #: (back of card)

Insurance Company Address:

Insured member Name:

Date of Birth:

Member ID #:

Group ID #:

Effective Date:

RX Group ID:

RX BIN #:

RX PCN:

Insured Member's Employer:

PHARMACY INFORMATION

Name of Pharmacy:

Pharmacy phone #:

Address:

Is your child currently on any controlled substance medication

Yes No

If yes, please complete the Controlled Substance Abuse Agreement.

If patient is a newborn, what hospital were they born at:

Date

If patient is transferring from another provider:

Name of Provider/Practice:

Address:

Phone #:

Fax #:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.