PATIENT INFORMATION
First Name __________________________________ Middle Initial ____ Last Name ______________________________________
Street Address __________________________________ City _________________________ State ________ Zip Code __________
Social Security Number _______ - _____ - ______
Telephone ( ______ ) ______-_______
Date of Birth ____ / ____ / _____
Cell ( ______ ) ______-_______
Employer _______________________________________
_____ M
_____F
Marital Status __________________________
Telephone ( ______ ) ______-_______
Address ________________________________________________________________________________
Street
City
State
Zip Code
RESPONSIBLE PARTY
If patient is a child or dependent, please complete this section
Name _________________________________ Relation to Patient _________________________ Date of Birth ____ / ____ / _____
Telephone ( ______ ) ______-_______
Social Security Number _______ - _____ - ______
_____ M
_____F
Address (if different from above) ________________________________________________________________________________
Street
City
State
Zip Code
REFERING PHYSICIAN
Name ______________________________________________________________________ Telephone ( ______ ) ______-_______
PRIMARY CARE PHYSICIAN
Name ______________________________________________________________________ Telephone ( ______ ) ______-_______
REASON FOR VISIT
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
INSURANCE INFORMATION
Primary Insurance ____________________________________________________________________________________________
ID #
Subscriber __________________________________________________________________________________________________
Name
Date of Birth
Relationship to Patient
Secondary Insurance __________________________________________________________________________________________
ID #
Subscriber __________________________________________________________________________________________________
Name
Date of Birth
Relationship to Patient
WORKERS COMPENSATION
Claim # ______________________________________________________________
Contact Person __________________________________________________________
Date of Injury ____ / ____ / _____
Telephone ( ______ ) ______-_______
I authorize any holder of medical or other information about me to release to the insurance payer or any of its agents any information
needed to determine payment/benefits for related services.
I also agree to be responsible for payment of any amount(s) not covered by my insurance plan or any amounts remaining after my
insurance plan has made payment, including all deductibles, co-payments and coinsurance. It is the Patient, Parent or Guardians
responsibility to know the terms of agreement/contract of your insurance policy.
___________________________________________________________________________________________________________
Signature of Patient, Parent, or Responsible Party
Date
