New Patient Demographic

Please print and fill the following Patient Demographic form and bring it with you to the clinic.

Patient Information                            
Please Print Clearly                               Date_______________
Patient name ___________________________________________ Sex___________________________
Birth date __________________ Age ____________       Marital Status     M     W     S     D
Address _____________________________________________________________________________
City _______________________________ State ___________________ Zip _____________________
Drivers License # ______________________________ Home Phone ____________________________
Day/Work Phone ____________________ Alternate Phone 1.__________________2._______________
E-Mail _____________________________Social Security # ___________________________________
Employer ____________________________________ Occupation ______________________________
Work Address __________________________________________________ Work # _______________
Next of Kin ___________________ Relationship ______________ Phone # _______________________
Emergency contact _____________ Relationship ______________ Phone # _______________________
Who Recommended Us? Name___________________________________________________________
Primary Care Physician: Name________________________________________________________________________________
Address______________________________________________________________________________
Phone____________________________
INSURANCE INFORMATION:
Insurance Name _____________________Member I.D. # _________________Group # ______________
 
Subscribers Info      (If insured under another person other than yourself)
Subscriber Name _________________________________________ Relationship __________________
Birth date ________________ Home phone _______________________
Address ______________________________________________________________________________
Social Security # _______________________________
Employer _____________________________________ Occupation _____________________________
Work Address ________________________________________________________________________
Is this a work or auto related injury? Yes__ No___           If yes please fill in information below.
Claim Number______________________ Insurance Address/Phone______________________________
 
I agree to pay all deductibles, co-pays, and non-covered charges assigned by my insurance carrier.
 
Sign________________________________               Date______________________