Intake Paperwork - Patient Information

PATIENT INFORMATION

First Name:  Middle Initial: Last Name:

Sex: Date of Birth: Age:

Social Security #:

Patient's Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Employer: Work Phone:

Marital Status: Single Married Divorced Other Email Address:

BILLING INFORMATION (Responsible for Bill)

Check this box if the info is the same as above

First Name: Middle Initial: Last Name:

Social Security #: Relationship to Patient:

Home Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Employer: Work Phone:

INSURANCE INFORMATION

Primary Insurance:

ID Number: Group Number:

Member's (Full) Name: Social Security #:

Date of Birth:

Employer: Relationship to Patient:

Secondary Insurance:

ID Number: Group Number:

Member's (Full) Name: Social Security #:

Date of Birth:

Employer: Relationship to Patient:

EMERGENCY CONTACT INFORMATION

Emergency Contact:

Home Phone: Cell Phone: Work Phone:

Relationship to Patient:

Known Drug Allergies:

REFERRING PHYSICIAN

Referring Physician: Phone:

Family Physician: Phone:

Has the patient been seen previously by any of our physician's?: Yes No

Is the reason for your visit due to an accident/worker's compensation? Yes No

If yes, please state the date of injury