Internal Medicine And Pediatrics Form
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1INTERNAL MEDICINE AND PEDIATRICS
224 High House Road, Suite #100
Cary , NC 27513
Phone (919) 380-7531
Fax (919) 380-0686
Patient’s Name: ________________________________________________ Age: _____________
Date of Birth: ____________________ Social Security #: _________________________
Race and Ethnicity: (Requested per Federal guideline. Please circle)
Ethnicity: Hispanic
Non-Hispanic
Race: American Indian or Alaska Native
Asian
Native Hawaiian
Black or African American
White
Hispanic
Other
Parent’s Names (IF PATIENT IS A MINOR)
Mother: _________________________________ Father: ________________________________
Home Address
Street: _________________________________________________________________________
City: ________________________ State: ___________ Zip Code:________________________
Phone Numbers
Home: __________________________
Business: ________________________ Cell ________________________________
Patient’s or Parent’s Work Information
Occupation: ____________________________________________________________________
Employer: _____________________________________________________________________
Employer Address: ______________________________________________________________
Patient’s or Parent’s Insurance Information
PRIMARY Insurance Company Name: ______________________________________________
Insurance Company Address: ______________________________________________________
Primary Name on Policy: _________________________________________________________
Date of Birth _______________ Social Security # _______________________________
Subscriber ID # _________________________ Group # ________________ Plan # __________
If Primary Insurance is Medicare, please indicate either A or B here: _______
SECONDARY Insurance Company Name: ___________________________________________
Primary Name on Policy: _________________________________________________________
Date of Birth _______________ Social Security # _______________________________
Subscriber ID # _________________________ Group # ________________ Plan # __________
List any allergies that you have: _________________________________________________________
Pharmacy
Name:____________________________Street:_________________________Phone:__________
Emergency Contact Information
Name: ________________________________________ Phone: __________________________
Relationship to Patient: ___________________________________________________________
Who can we thank for referring you to our practice? __________________________________________
I understand under HIPAA this office may use my Private Health Information (PHI) for treatment, payment, and health care without my
signed consent. Signing below indicates that I have received notice of privacy practices (HIPAA Policy) to review.
Printed Name: _____________________________________________
Signature: ________________________________________________ Today’s Date: _____________
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Parent category: Medical