(Please Print)

Today's Date:

PCP:   

TIENT INFORMATION

Patient's last name:      

First:      

Middle:      

 Mr.

 Mrs.

 Miss

 Ms.

Marital status:

 Single    Mar    Div    Sep    Widowed

Is this your legal name?

If not, what is your legal name?

(Former name):

Birth date:

Age:

Sex:

 Yes

 No

 M

 F

Street address:

Social Security no.:

Home phone no.:

(     )      

P.O. box:

City:

State:

ZIP Code:

Occupation:

Employer:

Employer phone no.:

(     )      

Chose clinic because: (Please check one box):

 Dr.

Hospital

  Family

Friend

 Close to home/work

 Yellow Pages

Other family members seen here:

INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)

Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

(     )      

Is this person a patient here?

 Yes

 No

Occupation:

Employer:

Employer address:

Employer phone no.:

(     )      

Is this patient covered by insurance?

 Yes

 No

Please indicate primary insurance

 Welfare (Please provide coupon)

 Other

Subscriber's name:

Subscriber's S.S. no.:

Birth date:

Group no.:

Policy no.:

Co-pay.:

$

Patient's relationship to subscriber:

Self                            Spouse                      Child                                  Other

Name of secondary insurance (if applicable):

Subscriber's name:

Group no.:

Policy no.:

Patient's relationship to subscriber:

 Self

 Spouse

 Child

 Other

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

(     )      

(     )      

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize or insurance company to release any information required to process my claims.

Patient/Guardian signature

Date