Demographic Sheet - Retina Care Specialists
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1SALUTATION: MR / MRS / MS / MISS / DR / ___________
GENDER: MALE / FEMALE
NAME _________________________________________________________________________
MARITAL STATUS: SINGLE / MARRIED / DIVORCED / WIDOWED
ETHNICITY: WHITE / AFRICAN AMERICAN / HISPANIC / OTHER ____________________________
PREFERRED LANGUAGE: ENGLISH / SPANISH / FRENCH / OTHER ___________________________
DATE OF BIRTH _______ /_______ /_______
SOCIAL SECURITY # _______ /_______ /_______
LOCAL ADDRESS __________________________________________________________________
LOCAL HOME # (
) ______________________ CELL # (
) ___________________________
WORK # (
) _______________________ EMAIL ______________________________________
SEASONAL ADDRESS _______________________________________________________________
SEASONAL PHONE # (
) ___________________________
DATES OF SEASONAL TRAVEL _______________________________________________________
LIVE IN ASSISTED LIVING FACILITY? YES/NO
ARE YOU IN REHAB/SKILLED NURSING? YES/NO
NAME AND NUMBER OF FACILITY ____________________________________________________
EMERGENCY CONTACT __________________________________PHONE # (
)_______________
RELATIONSHIP TO YOU _________________________ CONSENT TO SPEAK TO FAMILY YES / NO
REFERRED BY _____________________________________________________________________
PRIMARY CARE DR. _______________________________ PHONE # (
) ___________________
CARDIOLOGIST __________________________________ PHONE # (
) ___________________
PHARMACY / LOCATION / PHONE # ___________________________________________________
EMPLOYER _______________________________________________________________________
INSURANCE CO. __________________________________ PPO / HMO / OTHER _______________
POLICY HOLDER NAME _________________________________ DOB _______ /_______ /_______
SECONDARY INSURANCE CO. _________________________________________________________
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Parent category: Medical