Patient Encounter Form

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Audrey M. Weissman M.D.
ALLERGY ▪ ASTHMA ▪ IMMUNOLOGY
Rego Park Medical Associates, 59-10 Junction Boulevard, Elmhurst, New York 11373
Phone (718) .592-3200
Fax (718) 592-3844
PATIENT ENCOUNTER FORM
Patient’s Name
Date
Social Security Number
Date of Birth
Gender
Male
Female
Single
Married
Divorced
Widow/ed
Home Address
City, State, Zip Code
Home Telephone including area code
Cell Phone Number including area code
Best Phone Number (H / C/ B)
Email Address
Name of Employer
Employer City, State, Zip Code
Business Telephone including area code
If patient is Married write spousal information below, If patient is a Minor write Guardian information below:
Name
Employer
Telephone including area code
Insured ‘s Name
Primary Insurance (Name, Address & Telephone Number)
Secondary Insurance (Name, Address & Telephone Number)
Insured’s Name
Workers’ Compensation
YES
NO
No Fault
YES
NO
Contact In Case of Emergency (Other Than Spouse) :
Name
Relationship
Telephone including area code
Referred By:
NOTES:
Reason For Visit
Patient Encounter Form-AW
page 1 of 11
9/17/2013

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