New Patient Demographics

PATIENT DEMOGRAPHICS

Please complete this form prior to visit. All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Name

Date of Birth

Address

Phone

Primary care physician (name, phone, address)

Referring physician (name. phone, address)

Emergency contact (name, relation to patient, phone, address)

I authorize Rheumatology Center Of Houston to discuss my medical condition and/or treatment, if needed, with: (Name, relationship to me, phone number)

Responsible party address (If different than patient’s)

Primary insurance carrier (subscriber name and DOB, individual ID, group ID)

Secondary insurance carrier (subscriber name and DOB, individual ID, group ID

I do not have insurance

I agree to pay today for the services rendered by Rheumatology Center of Houston, PLLC.

Pharmacy information (name, address, phone, fax)

Leave a detailed message on voicemail.

Yes No

Leave a detailed message with individual answering the phone.

Yes No

Email you using an encryption software.

Yes No

Text you. You understand that standard charges will apply through your mobile carrier.

Yes No

Other requests for confidential communications:

Acknowledgement of receipt of privacy practices which can be viewed on our website at www.rheumatologycenterofhouston.com. Notice topatients: We are required to provide you with a copy of our Privacy Practices which state how we may use and/or disclose your healthinformation. Please sign your name below to acknowledge receipt of the Privacy Practices. You may refuse to sign the acknowledgement.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Acknowledgement of receipt of office policies which can be found on our website at www.rheumatologycenterofhouston.com. By signing myname below I acknowledge that I have read the office policies. I have had a chance to ask any questions that I had and to receive answers. Ihave been proactive about asking questions related to these policies. My questions have been answered and I understand and concur with theinformation provided in the answer.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

**Please text a photo (front and back) of your driver's license and insurance card**

New Patient Demographics will be submitted to Rheumatology Center Of Houston

Your information will be encrypted.