Patient Information

Patient Name

Patient SSN

Address

City/State/Zip

Phone (Home)

Phone (Work)

Phone (Cell)

Email

Marital Status

Gender

Date of Birth

Emergency Contact

Emergency Contact:

Relationship to Patient

Emergency Contact Phone

Preferred Language?

Race

American Indian

Asian

Black/African American

Native Hawaiian /Other Pacific Islander

White

Other

Ethnicity

Hispanic or Latino Not Hispanic or Latino

Referring Physician

May we discuss your care with your physician?

Yes No

Primary Care Physician

May we discuss your care with your physician?

Yes No

If none, how did you hear about our office?

Primary Health Insurance Company

Primary Insurance

Insured Name

Relationship to Patient

Insured Date of Birth

Insured Gender

Insured SSN

Insured Group Number

Insurance ID Number

Secondary Health Insurance Company

Do you have Secondary Insurance?

Yes No

Secondary Insurance

Insured Name

Relationship to Patient

Insured Date of Birth

Insured Gender

Insured SSN

Insured Group Number

Insurance ID Number

Guarantor/Responsible Party

Responsible Person

Relationship to Patient

Responsible Party Address

Responsible Party Phone (H)

Responsible Party Birthdate

Pharmacy Information

Pharmacy Name

Address

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.

Patient or Guardian Signature

Date

Patient Name

Patient’s Date of Birth