Patient Information Form printable pdf download

PATIENT INFORMATION FORM: PLEASE PRINT

Please fill this form out completely – ALL INFORMATION IS REQUIRED

PATIENT INFORMATION:

FIRST NAME ________________________________ MIDDLE INITIAL ________ LAST NAME_______________________________________

ADDRESS____________________________________________CITY ____________________________ STATE ________ ZIP_____________

DOB_______________________

SEX:

MALE

FEMALE

PHONE # _________________________

PARENT OR LEGAL GUARDIAN INFORMATION:

FIRST NAME____________________________________ LAST NAME_______________________________________ DOB ______________

ADDRESS_____________________________________________ CITY _____________________________STATE ______ ZIP_____________

HOME PHONE_____________________________ CELL PHONE____________________________ WORK PHONE______________________

EMPLOYER_________________________________________________________________________________________________________

PARENT OR LEGAL GUARDIAN INFORMATION:

FIRST NAME____________________________________ LAST NAME_______________________________________ DOB ______________

ADDRESS_____________________________________________ CITY _____________________________STATE ______ ZIP_____________

HOME PHONE_____________________________ CELL PHONE____________________________ WORK PHONE______________________

EMPLOYER_________________________________________________________________________________________________________

PRIMARY INSURANCE:

IS THIS AN AFFORDABLE CARE MARKETPLACE PLAN?

Y N

IF YES, PLEASE STOP AND SEE THE FRONT DESK

INSURANCE NAME_____________________________________ADDRESS______________________________________________________

POLICY HOLDER_________________________________________DOB____________ADDRESS_____________________________________

ID#_____________________________ GROUP#_______________________ SS# IF NEEDED FOR BILLING_____________________________

SECONDARY INSURANCE:

IS THIS AN AFFORDABLE CARE MARKETPLACE PLAN? Y N

IF YES, PLEASE STOP AND SEE THE FRONT DESK

INSURANCE NAME_____________________________________ADDRESS______________________________________________________

POLICY HOLDER_________________________________________DOB____________ADDRESS_____________________________________

ID#_____________________________ GROUP#_______________________ SS# IF NEEDED FOR BILLING_____________________________

PLEASE LIST ALL CHILDREN IN YOUR FAMILY WHO COME TO HAND IN HAND PEDIATRICS:

_____________________________________ __________________________________

____________________________

_____________________________________ __________________________________

____________________________

NEAREST NON-PARENT RELATIVE OR FRIEND NOT LIVING WITH YOU:

NAME:__________________________________________RELATIONSHIP:_______________________PHONE:________________________

HOW WERE YOU REFERRED TO THIS PRACTICE?

EXISTING PATIENT _____ PHYSICIAN _____ NAME OF PATIENT OR PHYSICIAN: ______________________________________________

NEWSPAPER _____ TELEPHONE _____ INTERNET _____ HAND IN HAND WEBSITE _____ INSURANCE CO _____

OTHER _______________________________________________________________________

Patient Information Form