Sports Physical Intake Form

PATIENT INFORMATION

Last Name:

First Name:

MI:

Social Security Number:

Date of Birth:

U.S. Military Service (Select One:)

None Currently Serving Discharged

Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email:

Marital Status (Select One):

Single Married Widowed Separated Divorced

Primary Language Spoken:

Limited English

Patient’s Relationship to Responsible Party (Select One):

Self Spouse Natural Child Parent Foster Child Foster Parent

Gender (Select One):

Male Female Choose Not To Disclose

Race (Select One):

American Indian/Alaska Native Asian Black/African American Native Hawaiian Other Pacific Islander White More than one Race Choose Not To Disclose

Ethnicity (Select One):

Hispanic/Latino Non-Hispanic/Latino Choose Not To Disclose

Are you a migrant/seasonal worker or a family member of a migrant/seasonal worker?

Yes No

What is your annual income?

$0-$14,580 $14,581-$18,225 $18,226-$21,870 $21,871-$25,515 $25,516-$29,160 $29,161 & UP

How many people (including you) does your income support?

Emergency Contact:

Phone:

Relationship to Patient:

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

Last Name:

First Name:

MI:

Mailing Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Date of Birth

Social Security Number:

INSURANCE COMPANY – INCLUDING MEDICAID

Primary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Secondary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Assignment and Release

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.

SIGNATURE:

DATE:

Consent for Treatment

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.

Patient, Parent, or Guardian Signature:

Date:

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