Patient Information (Confidential) Form

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Patient Information (Confidential)
Name________________________________________________________________________________________ Date________________________
First
Middle
Last
Address _______________________________________________ City____________________________________State_____________Zip________
Cell # ______________________________ Soc. security #___________________Birth date____________________Home phone_________________
Email ____________________________________________________________________________________________________________________
Check Appropriate Box
Minor
Single
Married
Divorced
Widowed
Separated
If college student, F.T./P.T., name of school__________________________________________________ City______________________State_______
Patient’s or parent’s employer_____________________________________________________________ Work phone__________________________
Business address ___________________________________ City________________________________State_____________________Zip________
Spouse or parent’s name _____________________________ Employer____________________________Work phone__________________________
Whom may we thank for referring you __________________________________________________________________________________________
Person to contact in case of an emergency ___________________________________________________ Phone______________________________
Responsible Party
Name of person responsible for this account _____________________________________________ Relationship to patient______________________
Address ___________________________________________________________________________Home Phone_____________________________
Driver’s license #__________________________________________Birth date__________________Soc. security #____________________________
Employer _________________________________________________________________________ Work phone______________________________
Is this person currently a patient in our office
Yes
No
Insurance Information
Name of insured __________________________________________________________________ Relationship to patient_______________________
Birth date _______________________________________ Soc. security #____________________________Date employed______________________
Name of employer________________________________ Union or local #____________________________Work phone________________________
Employer address _______________________________________ City______________________________State_______________Zip____________
Insurance co.___________________________________________ Tel. #_____________________Grp. #____________Policy/I.D. #_______________
Ins. co. address _________________________________________ City______________________________State_______________Zip____________
How much is your deductible ______________________________ How much have you used_____________Max annual benefit__________________
Do you have any additional insurance
Yes
No
If yes, complete the following:
Name of insured __________________________________________________________________ Relationship to patient_______________________
Birth date _______________________________________ Soc. security #____________________________Date employed______________________
Name of employer________________________________ Union or local #____________________________Work phone________________________
Employer address _______________________________________ City______________________________State_______________Zip____________
Insurance co.___________________________________________ Tel. #_____________________Grp. #____________Policy/I.D. #_______________
Ins. co. address _________________________________________ City______________________________State_______________Zip____________
How much is your deductible ______________________________ How much have you used_____________Max annual benefit__________________
X
_________________________________________________________
_______________________________
Signature of patient or parent if minor
Patient number

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