Patient Information Form

Patient Name:

Date:

Add parent/guardian

Who referred you to this office?

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Which phone number may we use to contact you to confirm appointments?

Email Address:

By providing my email address, I consent to the use of this form of communication

I consent to receive text messages, understanding that this is not a secure form of communication.

Yes No

Date of Birth:

Age:

Sex:

School/Employer (if applicable):

Grade:

Name of Preferred Pharmacy:

Phone:

Add allergy

Current medications (include times and dosages of all prescription and non-prescription medications, for example herbs and pain killers taken regularly)

Add medication

Name of person financially responsible, if other than patient, parent/guardian above:

Relationship:

Address:

City:

State:

Zip:

Social Security Number:

Date of Birth of Insured:

Note: This office does not accept insurance assignment as payment.

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.

Name of Adult Patient/ Parent or Guardian of Minor Patient:

Date:

Your information will be encrypted.