Weight Loss Program Patient Information Form

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IDEAL HEALTH CENTER
Date_________________
Name: ___________________________________________________ Preferred name: __________________________
Address: __________________________________________________________________________________________
City/State/Zip: _____________________________________________________________________________________
Phone #s (cell) _________________________________________ (work) _____________________________________
Email address: _____________________________________________________________________________________
SS# ______________________________________ Birthday _____________________________ Age ________________
Occupation _______________________________________________ Employer _________________________________
Marital status
⃝ Single
⃝ Married
⃝ Separated
⃝ Divorced
⃝ Widowed
Spouse’s name ____________________________________________________ Phone # __________________________
Children’s names and ages ____________________________________________________________________________
__________________________________________________________________________________________________
Favorite hobbies or interests __________________________________________________________________________
Emergency contact: Name ____________________________________________________________________________
Relationship ______________________________________________ Phone # __________________________________
Who may we thank for referring you? ___________________________________________________________________
Financial Responsibility
Who is responsible for the payment? ___________________________________________________________
How will you pay for your care?
⃝ credit/debit card
⃝ cash
⃝ insurance
Insurance co. ____________________________________
Phone # ______________________________________
ID # ____________________________________________
Group # ______________________________________
Subscriber’s name ___________________________________________________________________________________
Assignment and release
I, the undersigned certify that I (or my dependent) have insurance coverage with ________________________________
and assign directly to Ideal Health Center all insurance benefits, if any, otherwise payable to me for services rendered. I
understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the
doctor all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance
submissions.
_________________________________________
_____________________________
___________________
Responsible Party Signature
Relationship
Date
Health History
Are you receiving care from other health care professionals?
⃝ Yes
⃝ No
If yes, please name them and their specialty
__________________________________________________________________________________________________
_____________________________________________________________
Please list any drugs or medications you are taking ________________________________________________________
_________________________________________________________________________________________________

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