W E L C O M E

New Patient Demographic Form

Thank you for selecting our healthcare team! We will strive to provide you with the best possible healthcare. To assist us in meeting all your healthcare needs, please complete this form in its entirety. If you have any questions or need assistance, please contact us and we will be happy to assist you.

1. PERSONAL INFORMATION

Today's Date

Gender

M F

Minor

Patient Name

Birth Date

Address

City

State

Zip code

Social Security #

DL#

Employer

Occupation

Referred by

2. PHARMACY INFORMATION

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

3. CONTACT INFORMATION

Home Phone

Work Phone

Cell Phone

Email Address

Preferred method of contact

Phone Email

Emergency Contact

Name

Phone

Relationship

INFORMATION REGARDING YOUR CONDITION, TREATMENT OR DIAGNOSIS CAN BE GIVEN TO:

Name

Phone

Relationship

4. PRIMARY INSURANCE

Primary Insured

Date of Birth

Relationship to patient

Insurance Company Name

Insurance Company Claims Address

Group number

ID #

5. AUTHORIZATION AND RELEASE

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child or the person for whom I am responsible during the period of such care to third party payers and/or other health practitioners.

I authorize and request my insurance company to pay directly to the doctor any insurance benefits otherwise payable to me.

I understand that my insurance carrier may pay less than the actual bill for services. I Agree to be responsible for payment of all services rendered on behalf of myself or my dependent.

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 parent, if minor

Date

ADVANCED DIRECTIVE AND MEDICAL POWER OF ATTORNEY:

Do you have an Advance Directive for your medical care?

If yes, who is the designated person that will make decisions for you in the event that you are unable to do so

Signature of patient or parent, if minor

Your information will be encrypted.