Patient Information Form

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Comprehensive Blood & Cancer Center
PATIENT INFORMATION FORM
Date __________________
Spouse or Responsible Party
Name _________________________________
Name _____________________________________
Male
____
Female____
Address ___________________________________
Marital Status ___________________________
City________________ State___ Zip____________
Address ________________________________
Home Telephone #___________ Cell# ___________
City_____________State___Zip_____________
Social Security # _____________________________
Home Telephone # _________ Cell#__________
Date of Birth _______________ Age ____________
Email Address
__________________________
Employer ___________________________________
(If minor, responsible party’s e-mail)
Work Telephone # ____________________________
Date of Birth________________ Age _________
Social Security # __________________________
Employer ________________________________
Person to Contact in Case of Emergency:
Work Telephone # _________________________
Permission to discuss my treatment, diagnostic tests,
Occupation: ______________________________
and medical condition:
□
Yes
□
No
If Student, Name of School: _________________
Name _____________________________________
_________________________________________
Address ____________________________________
Language Spoken: _________________________
City _________________ State ___ Zip _________
Race: □ White
□ Black
□ Hispanic
Telephone # _________________________________
□ Decline to Answer □ Other __________
Relationship to Patient _________________________
□ Hispanic □ Non-Hispanic
Ethnicity:
□ Declined to Answer
Please bring your insurance card(s) with you and prescription card with you and present them to the
Receptionist when you arrive for your appointment.
PRESCRIPTION DRUGS: To better meet our patients’ needs we can dispense some of the prescriptions
as prescribed by our physician(s). We will bill your pharmacy insurance and charge the applicable co-pay.
Pease understand that you are not obligated to have prescriptions filled here and you have the option of
receiving your medications from the pharmacy of your choice. We would be happy to facilitate this for you.
NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of
California. (800) 633-2322 or
______________________________________________________________________
Patient’s Name
Patient’s Signature
Date Signed
4
UCLA Affiliated Medical Center · Website:
6501 Truxtun Avenue · Bakersfield, CA 93309 · (661) 322-2206 · FAX (661) 322-7027
1310 Las Tablas Road, Suite 204 · Templeton CA 93465 · (805) 434-0333 · FAX (805) 434-0893

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