Patient Demographic Sheet Template

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PATIENT DEMOGRAPHIC SHEET
Name: ________________________________________________ Today’s Date: _______________________
Address: __________________________________________________________________________________
Home Phone: ____________________ Cell Phone: ____________________ Work: ____________________
Date of Birth: _______________________ Social Security Number:
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Email address: ______________________________________
Gender:
Male
Female
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Marital Status:
Minor
Single
Married
Widowed
Separated
Divorced
Other
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Race:
Caucasian
African American
Other
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Ethnicity:
Hispanic/Latin American
Caucasian
Hawaiian
African American
Asian
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American Indian
Other
Preferred Language:
English
Spanish
Other: __________________
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Employment Status:
Full-time
Part-time
Retired
Disabled
Unemployed
Student
Employer Name (if applicable): ________________________________________________________________
Responsible Party (if under 18 years of age): _____________________________________________________
If student, name of school: _______________________________ City/State ___________________________
Spouse or Parent’s name: ________________________________ Employer: __________________________
Person to contact in case of emergency: ________________________________ Phone: __________________
Relationship to patient: ___________________________
I have read and understand the office HIPAA policy and understand that I can request a paper copy of the HIPAA policy.
All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made prior
to this appointment.
If I have insurance coverage, I hereby authorize my physician to furnish information to that insurance carrier concerning my illness and treatment. I hereby assign
to the physician all payments for medical services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by my
insurance.
Patient/Guardian Signature: ___________________________________________ Date: _________________

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