979-345-6522
Social Security Number
Birth Date
Driver's License NumberHome Address
City
State
Zip
Primary Phone
Phone Type
homecell
Phone Number
homecellother
E-mail Address
Employer's Name
Occupation
Relation
Yes NoIf yes, Doctor's name?
Preferred Pharmacy
Yes NoIf yes Job-related Automobile Home Other
Please describe
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Policy Holder's Social Security Number
Policy Holder's Date of Birth Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Yes NoReason
Physician
Last Visit
Phone
Yes No
What kind?
How often?
Yes No Previously
No. of years?
Packs per day?
When did you quit?
Yes NoHow often do you drink alcohol?
Yes NoHow often do you drink coffee or other caffeinated beverages?
Yes NoHow many times per week?
(Women only) Are you pregnant or nursing?
Yes No N/A
Are you taking birth control pills?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims and to any Physician or Health Care Provider to whom I might be referred for medical reasons. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics.
Patient Signature and/or Responsible Party
Date