Client Record Form

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Client Record Form
L. Name_________________________ F. Name _______________________ M.I. _____
Address_________________________________________________________________
City ____________________ State ___________ Zip _____________
Home Phone # (___)____-______ Work # (___)_____-______ Cell # (___) ____-_______
Social Security # ____ - ___ - _______ Birth Date _____/_____/______
Married ____Yes ____No
Insurance Information
Ins. Co. Name ____________________________________________________________
Policy ID # __________________________________ Group # _____________________
Ins. Co. Address __________________________________________________________
City _________________ State ______ Zip _______________
Phone # (____) _____-______ 800 # (____) ________-__________
Name on Policy L.___________________ F. ____________________ M.I. __________
Address____________________________________
* (If different from above)
City ________________ State ____ Zip ___________
D.O.B. ____/____/_______
Home Phone # (____) ______-__________
* (If different from above)
Patient Relationship to Insured: ______Self ____Spouse _____Child _____Other
Employer or School Name _____________________________________________
Emergency Point of Contact
Name_____________________________ Relationship ________________________
Home Phone # (____) ____-______ Work Phone # (____) ____-______
Guardian Information
*(If different from above)
L. Name _______________ F. Name ______________ M.I.______
* I understand that if my Insurance Company fails to pay, I’m responsible for payment of all bills.
Signature _________________________________

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