Patient Information Form

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PATIENT INFORMATION
Patient Name _________________________________________________________________________________________
(last)
(first)
(middle)
Address _____________________________________________________________________________________________
(city)
(state)
(zip)
Date of birth __________________________(mm/dd/yyyy)
SSN _____________________________________________
Current Gender Identity: ☐Male ☐Female ☐ Transgender __T__☐ Additional Category (please specify) ______________
Home phone (
) ________________ Cell phone (
) ___________________ Email __________________________
Employer __________________________________________________________________ Work Phone _______________
Business Address ______________________________________________________________________________________
(city)
(state)
(zip)
Spouse’s name ____________________________ Employer ________________________ Work Phone ________________
Name of Primary Care Provider (PCP) _____________________________________________Tel ____________________
Address of clinic ______________________________________________________________ Fax ____________________
Referring Person (if not PCP) _____________________________________________________Tel ____________________
Address _____________________________________________________________________ Fax_____________________
Emergency Contact Information
Name of friend/or nearest relative not living with you __________________________________ Phone _________________
Address _________________________________________________________ Relationship to you:___________________
Insurance Information
Name of insured ____________________________________________ Relationship to patient _______________________
(last)
(first)
(middle)
Address _______________________________________________________ Contact phone __________________________
Name of employer _______________________________________________________ Work phone ___________________
Primary Insurance Company _____________________________________ ID# ______________ Group # ______________
Address ________________________________________________city ____________ state _________ zip ____________
Secondary Insurance Company ___________________________________ ID# ______________ Group # ______________
Address ________________________________________________city ____________ state _________ zip ____________
Would you like to be invited to enroll in our patient portal where you can view appointment information and lab results (from
select laboratories) ☐Yes ☐No
I authorize release of any information concerning my health care, advice and treatment provided for the purpose of evaluating
and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to
me directly to the doctor. I understand I am responsible for payment of all services rendered including payment of expenses
not paid by my insurance.
________________________________________________
________________
Signature of Patient
Date
Patient Information
vApril122016

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