PATIENT INFORMATION

First Name __________________________________ Middle Initial ____ Last Name ______________________________________

Street Address __________________________________ City _________________________ State ________ Zip Code __________
Social Security Number _______ - _____ - ______
Telephone ( ______ ) ______-_______

Date of Birth ____ / ____ / _____

Cell ( ______ ) ______-_______

Employer _______________________________________

_____ M

_____F

Marital Status __________________________

Telephone ( ______ ) ______-_______

Address ________________________________________________________________________________
Street

City

State

Zip Code

RESPONSIBLE PARTY
If patient is a child or dependent, please complete this section

Name _________________________________ Relation to Patient _________________________ Date of Birth ____ / ____ / _____
Telephone ( ______ ) ______-_______

Social Security Number _______ - _____ - ______

_____ M

_____F

Address (if different from above) ________________________________________________________________________________

Street

City

State

Zip Code

REFERING PHYSICIAN
Name ______________________________________________________________________ Telephone ( ______ ) ______-_______
PRIMARY CARE PHYSICIAN
Name ______________________________________________________________________ Telephone ( ______ ) ______-_______
REASON FOR VISIT
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
INSURANCE INFORMATION
Primary Insurance ____________________________________________________________________________________________
ID #

Subscriber __________________________________________________________________________________________________
Name

Date of Birth

Relationship to Patient

Secondary Insurance __________________________________________________________________________________________

ID #

Subscriber __________________________________________________________________________________________________
Name

Date of Birth

Relationship to Patient

WORKERS COMPENSATION
Claim # ______________________________________________________________
Contact Person __________________________________________________________

Date of Injury ____ / ____ / _____

Telephone ( ______ ) ______-_______

I authorize any holder of medical or other information about me to release to the insurance payer or any of its agents any information
needed to determine payment/benefits for related services.
I also agree to be responsible for payment of any amount(s) not covered by my insurance plan or any amounts remaining after my
insurance plan has made payment, including all deductibles, co-payments and coinsurance. It is the Patient, Parent or Guardians
responsibility to know the terms of agreement/contract of your insurance policy.

___________________________________________________________________________________________________________
Signature of Patient, Parent, or Responsible Party
Date