Patient Information Form

Please correct the errors described below.

Last Name

First Name

Initial

Sex

Male Female

Social Security

Date of Birth

Marital Status

Home Address

City

State

Zip

Mailing Address if different

Home #

Work #

Cell #

OK to leave a message at:

Home

Work

Cell

Occupational Status

Disabled Retired Not Employed Student: FT Student: PT

Employer

Address

FT/PT

Emergency Contact

Phone

Relation

Pharmacy

Location

Referring Physician

Primary Care Physician

Primary Insurance Carrier

ID #

Group #

Insured Date of Birth

Name of the Insured

Relation to the Patient

Second Insurance Carrier

ID #

Group #

Insured Date of Birth

Name of the Insured

Relation to the Patient

Third Insurance Carrier

ID #

Group #

Insured Date of Birth

Name of the Insured

Relation to the Patient

I hereby authorize payment of medical benefits billed to my insurance. I hereby accept full responsibility for payment for any service(s) provided to me but not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the Practice does not participate with my insurance. I agree to pay all copayments, coinsurance and deductibles at the time service is rendered.

I will pay by (check all that apply)

Cash

Check

Credit Card

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.

Signature of Patient or Guardian/Responsible Party

Date

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Electronic signature

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