Patient Information Care Sheet printable pdf download

Patient Information Care Sheet

Date_____________________

Name_________________________________________________________________________________________

(Last)

(First)

(Middle Initial)

Home Address: ______________________________________________________ Apt. #:_____________________

City: _________________________________________ State: ___________________ Zip Code: _______________

Best Contact phone number

Day:_(______)_________________________ Home Work Cell (Please Circle One)

Evening: (______)___________________ Home Work Cell (Please Circle One)

If you are unavailable may we leave a message with another person? YES

NO (please circle one)

If yes, with whom? _________________________________________________________

May we leave medical information on an answering machine/voicemail? YES NO (please circle one)

Social Security Number: _____________________________ Birthdate: ___________________________________

Your Employer: ____________________________________ Job Title: ____________________________________

Work Address: ____________________________________Work Telephone: (_____)________________________

Do you currently have insurance? yes no If yes, name of carrier: _____________________________________

Guarantor Name (if the patient is a minor or student):_______________________ Relationship________________

Sex: Male Female

Marital Status: Single Partnered Widowed Married Divorced

Preferred Language: English Indian Russian Spanish Other

Ethnicity: Hispanic or Latino

Race: American Indian Black or African America

Non-Hispanic or Latino

Asian

White

Refuse to Report

Native Hawaiian Hispanic

 Other

E-mail (For Patient Portal Signup only):___________________________________________________________________

In Case of Emergency: First Name: ______________________________Last Name:_______________________________

Relationship_____________________________________Phone Number: (____)_________________________________

In order to control our costs of billing, we require that office visits be paid at the time of service is rendered, unless prior arrangements have been made.

Authorization: I hereby authorize my physician to furnish information to insurance carriers concerning this illness/accident, and hereby

irrevocably assign the doctor all payment for medical service rendered. I understand that I am responsible for charges whether or not covered

by insurance.

X______________________________________

Responsible Party Signature

Patient Information Care Sheet

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