979-345-6522
Social Security Number
Birth Date
Driver's License Number
Home Address
City
State
Zip
Primary Phone Primary Phone
Phone Type
Home Cell
Secondary Phone Secondary Phone
Home Cell Other
E-mail Address *
Employer's Name
Occupation
Yes No If yes, Doctor's name?
Preferred Pharmacy
Yes No If yes Job-related Automobile Home Other
Please describe
Phone Number
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Date of Birth
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Yes No Reason
Physician
Last Visit
Phone
Yes No
What kind?
How often?
Yes No Previously
No. of years?
Packs per day?
When did you quit?
Yes No How often do you drink alcohol?
Yes No How often do you drink coffee or other caffeinated beverages?
Yes No How 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. 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 understand that where appropriate, credit bureau reports may be obtained.
