PATIENT INFORMATION SHEET

NAME:

SS#:

PARENT/GUARDIAN'S NAME (If Applicable):

DATE OF BIRTH:

STREET:

CITY:

STATE:

ZIP:

HOME:

CELL #:

BUSINESS #:

MARITAL STATUS:

S M W D

SEX:

M F

SPOUSE’S NAME:

SPOUSE EMPLOYER/ADDRESS:

EMERGENCY CONTACT:

TEL#:

RELATIONSHIP:

REFERRED BY:

PHYSICIAN

If checked, please provide doctor's name:

HMO BOOK

YELLOW PAGES

HOSPITAL

If checked, please provide hospital:

FRIEND/RELATIVE

If checked, please provide friend's/relative's name:

OTHER

If checked, please specify:

PATIENT EMPLOYER INFORMATION

OCCUPATION:

EMPLOYER NAME:

TEL#:

EMPLOYER ADDRESS:

CITY/STATE:

ZIP:

INSURANCE INFORMATION

PRIMARY INSURANCE CO. NAME:

POLICY #:

POLICY ID#:

RELATION:

SELF SPOUSE CHILD

SECONDARY INSURANCE CO. NAME:

POLICY #:

GROUP #:

GENERAL MEDICAL INFORMATION

DESCRIBE CURRENT MEDICAL PROBLEM/REASON FOR TODAY’S VISIT/ IF ACCIDENT, HOW IT HAPPENED:

IF INJURY IS A RESULT OF WORK – PLEASE COMPLETE

DATE OF ACCIDENT:

BRIEF DESCRIPTION OF HOW ACCIDENT HAPPENED:

CLAIM#:

NAME AND ADDDRESS OF PERSON RESPONSIBLE FOR BILLING:

IF INJURY IS A RESULT OF A MOTOR VEHICLE ACCIDENT – PLEASE COMPLETE

DATE OF ACCIDENT:

CLAIM#:

AUTO INS. CO.:

AUTO INS. CO ADDRESS:

OTHER PHYSICIANS TREATING YOU:

PHYSICIAN NAME:

Add more

PREVIOUS OR OTHER MEDICAL PROBLEMS/INJURIES:

MEDICAL PROBLEMS/INJURIES:

Add more

LIST ANY PREVIOUS HOSPITALIZATIONS/SURGERIES:

HOSPITALIZATIONS/SURGERIES:

Add more

PRESENT MEDICATION(S):

ALLERGIES TO MEDICATIONS:

Add more

ALLERGIC TO LATEX?

YES NO

FEMALES ONLY:

ARE YOU PREGNANT, PLANNING A PREGNANCY OR NURSING A CHILD?

YES NO

DO YOU SMOKE?

YES NO

# OF YEARS:

HOW MUCH?

DO YOU REGULARLY DRINK ALCOHOL?

YES NO

HOW MANY OUNCES/BEERS A DAY?

DO YOU REGULARLY DRINK COFFEE?

YES NO

HOW MANY CUPS PER DAY?

PERSONAL MEDICAL HISTORY

ASSIGNMENT OF BENEFITS

PAYMENT IS TO BE MADE WHEN PATIENT CARE IS RENDERED

EXCEPT

IN THE CASE WHEN WE CAN PARTICIPATE IN THE HMO YOU ARE ENROLLED IN. THEN THE FOLLOWING IS APPLICABLE.

I ASSIGN DR. TOBENNA OKEZIE, BENEFITS UNDER ANY INSURANCE CONTRACTS FOR PAYMENT FOR SERVICES RENDERED TO ME BY HIM OR HIS ORDER.

THE FOLLOWING IS APPLICABLE TO ALL PATIENTS:

I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO PROCESS ANY CLAIMS ON MY BEHALF FOR SERVICES RENDERED TO ME. I DIRECT THAT ALL SUCH PAYMENTS GO DIRECTLY TO DR. TOBENNA OKEZIE.

I AUTHORIZE ANY PHYSICIAN, HOSPITAL OF MEDICAL CARE FACILITY TO PROVIDE ALL INFORMATION ON MY MEDICAL HISTORY AND TREATMENT TO THE ABOVE NAMED PROVIDER.

I AUTHORIZE DR. TOBENNA OKEZIE TO INITIATE A COMPLAINT TO THE INSURANCE COMMISSIONER, FOR ANY REASON, ON MY BEHALF.

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.

PATIENT/GUARDIAN SIGNATURE:

DATE:

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