Patient Information Template printable pdf download

Patient Information Template

PATIENT INFORMATION

Patient Name:

Date of Birth:

Address:

Street:

City: _______________________________________________________ State: ________ Zip_______________

Home Telephone:

Cell Phone:

Work Phone:

E-mail:

Preferred method of communication? Please check one:

Home

Cell

Work

E-mail

Social Security Number:

Driver’s License Number:

Employer:

Emergency Contact:

Relation:

Phone:

Primary Insurance:

Name of Responsible Party/Subscriber

Date of Birth:

Secondary Insurance:

Name of Responsible Party/Subscriber

Date of Birth:

Primary Doctor:

Phone:

Referred by:

Doctor:

Phone:

Website:

Family/Friend:

Other:

I hereby certify that the above information is true to the best of my knowledge. I authorize the release of any medical

or other information necessary to process claims on my behalf. I agree to be fully responsible for all lawful debts

incurred by myself for services received from OC Ear, Nose and Throat Physicians and staff, whether covered by

insurance or not.

Patient’s or Patient Representative’s Name and Signature

Date

Patient Information Template