Patient Data Sheet (Demographics)

PATIENT DATA SHEET

Date Completed:

Patient Information

Last Name:

First Name:

MI:

Other name known by:

Male Female

Birthdate:

Social Security #:

Home Phone #:

Local Address:

APT. #:

City, State

Zip Code:

PRIMARY LANGUAGE SPOKEN IN HOME:

OTHER LANGUAGES SPOKEN

Ethnicity

Hispanic Non-Hispanic

If Other, Please Specify:

GENDER IDENTITY:

Male Female Genderqueer Female-to-Male(Trans Male) Male-to-Female(Trans Female) Other Unknown Decline to answer

SEXUAL ORIENTATION:

Straight or Heterosexual Gay, Lesbian or Homosexual Bisexual Other Unknown Decline to answer

PARENT #1 INFORMATION

Mother Stepmother Legal Guardian

Name:

D.O.B

SS#:

Cell Phone #:

Work Phone #:

Email:

Address(If different from child):

City, State:

Zip Code:

PARENT #2 INFORMATION

Father Stepfather Legal Guardian

Name:

D.O.B

SS#:

Cell phone #:

Work Phone #:

Email:

Address(If Different from child):

City, State

Zip Code:

May we leave detailed messages on your voicemail?

Yes No

May we use text/email for appointment reminders?

Yes No

If given the option, based on availability, which provider would you prefer to see at every visit?

Add Siblings

Add Children

EMERGENCY INFORMATION

Who may we contact in case of emergency that is not the parent(s)?

Name:

Relationship:

Phone:

Address:

INSURANCE INFORMATION

Add more

Preferred Pharmacy Name:

Pharmacy Location:

May we retrieve your child’s prescription history?

Yes No

May we update your child’s vaccines in the FL Immunization Registry?

Yes No

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

Parent Signature:

Date:

Your information will be encrypted.