Patient Information Template
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8GWINNETT OB/GYN ASSOCIATES, P.C.
Today’s Date: ______________________
Chart #: _________________
PATIENT INFORMATION (please print – blue or black ink only)
Name: _________________________________________________________ Age:_______ Birth Date: _______________________
Last
First
MI
Address: ___________________________________________ City: ____________________ State: ______ Zip: ________________
Home Phone: ____________________ Cell Phone: ____________________ E-Mail Address: _______________________________
Social Security Number: ______________________________
Primary Care Physician: ___________________________________
Employed? (circle one)
Yes
No
Full-time Student? (circle one)
Yes
No
Employer: ___________________________________ Work Phone: _____________________ Occupation: ____________________
Work Address: ___________________________________ City: _____________________ State: _____ Zip:___________________
Marital Status (circle one) Single Married Divorced Widowed
Who referred you here? ___________________________
SPOUSE INFORMATION
Name: ________________________________ Social Security Number: ________________________ Birth Date: ______________
Employer: _______________________________ Work Phone: _____________________ Cell Phone: _________________________
Work Address: __________________________________ City: _____________________ State: _____ Zip: ____________________
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name: _______________________________________________________ Relationship: ___________________________________
Address: ________________________________________ City: ______________________ State: _____ Zip: __________________
Home Phone: ________________________ Work Phone: ________________________ Cell Phone: __________________________
INSURANCE INFORMATION
Primary Insurance Co. Name: __________________________ Group #: ____________________ ID# _______________________
Address: ________________________________________ City: ______________________ State: _____ Zip: __________________
Policy Holder’s Name: ___________________________________ Social Security Number: _________________________________
Date of Birth: __________________________________ Relation to Patient (circle one)
Self
Spouse
Mother Father
Other
Secondary Insurance Co. Name: _____________________________ Group #: __________________ ID#: ___________________
Address: ________________________________________ City: ___________________ State: _____ Zip: _____________________
Policy Holder’s Name: ____________________________________ Social Security Number: ________________________________
Date of Birth: __________________________________ Relation to Patient (circle one)
Self
Spouse
Mother Father
Other
I authorize the release of any medical information necessary to process insurance claims. My signature also authorizes
payment of medical benefits to the named provider for professional services rendered. I understand that I am financially
responsible for all services rendered, that there is a $30 returned check fee and that 30% will be added to my balance if my
account must be referred to an agency for collection. Additionally, I understand that if I am covered by an insurance that
requires a referral number, it is my responsibility to obtain that referral number prior to my visit.
____________________________________________
_____________________
(Patient’s Signature)
(Date)
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