Patient Information Form

Last Name

First Name

M.I.

Street Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

(if ok to call you at work)

Social Security #

Email address

DOB

Sex

Marital Status

Preferred Pharmacy

Employer

Occupation

Are you on Medicare?

Yes No

Insurance Company

Member ID #

Referred By

Spouse

Spouse's Phone #

Are you currently seeing another psychiatrist?

If yes, what is the reason for today’s visit (Please select one)

I want to change doctors I would like a 2nd opinion Other

If other, please specify.

This office does not file for insurance. For private insurance we will provide you with a receipt to allow you to file your claim. This provider is not a participant of the Medicare/Medicaid insurance programs.

Medications patient may be allergic to

IN CASE OF EMERGENCY

Name

Relationship

Home Phone

Work Phone

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.

Signed

(THIS FORM MUST BE SIGNED AND DATED)

Date

Your information will be encrypted.