DEMOGRAPHIC AND INSURANCE INFORMATION FORM

Today's Date:

Patient's Date of Birth:

Patient's First Name:

Last Name:

Address:

City:

State:

Zip Code:

Home Phone Number:

Who does the patient live with?

Primary Language Spoken in Home:

Secondary Language:

Ethnicity:

Hispanic/Latino Not Hispanic/Latino Unknown

Race:

American Indian/Alaskan Native Asian Black White Pacific Islander/ Hawaiian Native

Parent’s Marital Status (please circle one):

Married Single Mother Divorced, Shared Custody Divorced, Sole Custody Mother/Father Two Mother’s Two Father’s Grandparent as Guardian Other:

Other:

Mother’s First Name:

Mother’s Last Name:

Mother's Date of Birth:

Please select:

Biologic Foster Adoptive Other:

Other:

Mother’s Address (if different from patient’s):

City:

Status:

Zip Code:

Mother’s Primary Phone Number:

Home Cell

Phone Number:

Mother’s SSN:

Mother’s Email:

Father’s First Name:

Father’s Last Name:

Father's Date of Birth:

Please select:

Biologic Foster Adoptive Other:

Other:

Father’s Address (if different from patient’s):

City:

State:

Zip Code:

Father’s Primary Phone Number:

Home Cell

Phone Number:

Father’s SSN:

Father’s Email:

Emergency Contact (other than parent):

First Name:

Last Name:

Relationship to child:

Cell/Home Phone Number:

Insurance Info:

Primary Insurance Name:

Member ID Number:

Primary Insurance Holder’s First Name:

Last Name:

Insurance Holder’s Date of Birth:

Relationship to Patient:

Insurance Holder’s SSN:

Insurance Holder’s Place of Employment:

City:

State:

Zip Code:

Secondary Insurance Name:

Member ID Number:

Secondary Insurance Holder’s First Name:

Last Name:

Insurance Holder’s Date of Birth:

Relationship to Patient:

Insurance Holder’s SSN:

Insurance Holder’s Place of Employment:

City:

State:

Zip Code: