Patient Information Check-In Sheet - New Horizons Women'S Care

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Patient Information
Check-in Sheet
Date_____________________
Name _______________________________________
SS# ___________________________
Home Ph #_______________________
Address___________________________________________
DOB _____________________
Mobile Ph#_______________________
City __________________
State ____
Zip ____________
Single
Married
Divorced
Work Ph #_______________________
Occupation___________________
Employer ____________________________________
Other Ph #_______________________
Ethnicity_____________________
Preferred Language_____________________________
Email Address___________________________________________________________________
Name of Primary Care Physician_____________________________________________________
Phone # _________________
How did you hear about our office? ___________________________________________________
Spouse (if married) or Parent (if minor)
Name ___________________________
SS# ___________________
Ph # ____________________________
Address ___________________________________________
DOB ____________________
City __________________
State ____
Zip _____________
Relationship_______________
Employer __________________________
Occupation _________________________________
Work Ph # ________________________
Emergency Contact
Name _______________________________________
Relationship_____________________
Daytime Ph # ______________________
Insurance Information
Primary Insurance______________________________________
Secondary Insurance ___________________________________________
Address ______________________________________________
Address _____________________________________________________
City __________________
State _____
Zip _____________
City ______________________
State ____
Zip _____________
Ph# ____________________________
Ph# ____________________________
Policy Holder Name _________________ ___________________
Policy Holder Name _________________ ___________________
Relationship to Patient __________________________________
Relationship to Patient __________________________________
Employer _____________________________________________
Employer _____________________________________________
ID# ____________________________
Gr# _______________
ID# ____________________________
Gr# ________________
DOB ____________________
DOB ____________________
Policy Holder Sex
F
M
Policy Holder Sex
F
M
Please carefully read and sign both statements below:
It is understood that I, or we, will be responsible for all charges incurred on this account, to include all present and future services. I understand that
regardless of the insurance coverage that I may have, I am responsible for paying all charges. In event of non-payment of charges for the services
rendered, I agree to pay all costs of collection, including reasonable attorney’s fees. I have read this agreement and do understand its provisions.
Patient or Responsible Party ___________________________________________________ Date _________________________________
I hereby authorize Arizona OBGYN Affiliates to send me newsletters, bulletins, and other documents via email. I understand that Arizona OBGYN
Affiliates will not share my email address with any other person or agencies without my express, written consent. This authorization will remain in
effect until I revoke this authorization.
Patient or Responsible Party ___________________________________________________ Date _________________________________

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