» Patient Resources

Patient Information

Name:

S.S.#:

DOB:

Address:

City:

State:

Zip Code:

Home Phone #:

Cellphone #:

Email:

preferred Method of Contact:

Home
Cell
Email

Sex

Male
Female

Race/Ethnicity:

Student Status:

Student: Full-time
Student: Part-time
Not a Student

Employment Status:

Employed: Full-time
Employed: Part-time
Unemployed
Retired
Homemaker

Employer:

Work #:

Employer's Address:

Emergency Contact Name:

Emergency Contact cellphone #:

Relationship:

PARENTS/GUARDIANS INFORMATION

*** Please complete if patient is under 18 years old ***

Name:

DOB:

Gender:

Relationship to Patient:

If different from the above: Address:

City/State::

Zip Code:

Home #:

Cellphone #:

INSURANCE INFORMATION

Primary Insurance Name:

ID#:

Insurance Policy Holder:

Self

Name of Policy Holder :

Policy Holder’s Relationship to Patient:

Policy Holder’s DOB:

Insurance Type:

Individual Plan
Family Plan

Secondary Insurance Name:

ID#:

Insurance Policy Holder:

Self

Name of Policy Holder :

Policy Holder’s Relationship to Patient:

Policy Holder’s DOB:

Insurance Type:

Individual Plan
Family Plan

ADVANCE DIRECTIVES:

Do you have a Healthcare Proxy

Yes
No

(if yes, please ask receptionist for Healthcare Proxy form upon visit)

Do you have a Living Will?

Yes
No

Do you have a Power of Attorney

Yes
No

*** If yes to any of the above, please submit documentation***

If no to any above, would you like to create one at this time?

Yes
No