Adult Patient Packet - Community Quick Care printable pdf download

*Please provide our office staff with your insurance card and photo ID so that we may scan into our system.

Patient Name: ___________________________________ Sex: _____ Date of Birth: ____________________

Home Address: ______________________________________________________________________________

City

State

Zip

Home Number: _________________ Work Number: ________________ Cell Number: __________________

Social Security Number: ________________________ Employer: _____________________________________

Marital Status: ____________________ Email Address: _____________________________________________

Pharmacy Name: _____________________________________ Location: ______________________________

How did you hear about Community Quick Care? ___________________________________________________

INSURANCE INFORMATION

Primary Insurance Company: ___________________ ID #: ___________________ Group #: _______________

Subscriber’s Name: _______________________________________ Subscriber’s DOB: ___________________

Second Insurance Company: ___________________ ID #: ___________________ Group #: _______________

Subscriber’s Name: _______________________________________ Subscriber’s DOB: ___________________

VERBAL CONSENT

These individuals may receive verbal information about my chart or speak to our office staff on my behalf:

Name: _____________________________ Date of Birth: ______________ Relationship: ______________

EMERGENCY CONTACT

Name: __________________________ Relationship: _________________ Phone: _____________________

Home Address: ______________________________________________________________________________

City

State

Zip

Your signature on this form authorized us to receive payment and release medical information to your health insurance company. All other

releases of medical records require additional authorization. Should our office have a need to leave a message on your cell concerning your

appointment, your signature on this form gives us that permission. Your signature also indicates that you have received a copy of the HIPPA

regulations (if requested), and you are giving us consent to treat you for your medical conditions.

________________________________________________________________

____________________________

PATIENT’S SIGNATURE

DATE

Adult Patient Packet - Community Quick Care