Demographic Information Form (Page 2 of 2) in pdf

Demographic Information Form Page 2

Medical Record#________________

(office use only)

Emergency Contact Information:

Name: ___________________________ Relation:__________________ Phone:______________________

Primary Caregiver (if applicable):_______________________________________ DOB_________________

(Person who provides day‐to‐day care for the patient)

Name

Legal Guardian (for minors):_________________________________________ DOB _________________

Name

Do you have legal documents? YES NO

If yes, please submit appropriate documents to front desk staff

(Non‐applicable for children under the age of 18)

Do you have a Power of Attorney or Health Care Proxy/Surrogate? YES NO

(An “agent” designated by the patient, the patient’s family, or by the courts to make health care decisions for him or her in the event that the

patient is unable to do so)

If YES, please submit appropriate documents to front desk staff

Do you have a Living Will or Advance Directives? YES NO

(Documents which give the patient a voice in decisions about their medical care when he/she is unconscious or too ill to

communicate)

If YES: Please submit to front desk staff to be copied

If NO: And you would like additional information, please ask front desk staff for an informational packet

Patient Signature:_________________________________________

Date:__________________

Demographic Information Form Page 2