Patient Information
- Full Legal Name: ______________________________
- Date of Birth: //_____
- Social Security Number: --_____
- Gender: □ Male □ Female □ Other □ Prefer not to say
- Marital Status: □ Single □ Married □ Divorced □ Widowed
Contact Information
- Street Address: _________________________________
- City: _____________ State: _____ ZIP: ________
- Home Phone: (_) -
- Mobile Phone: (_) -
- Email: _____________________________________
- Preferred Contact Method: □ Phone □ Email □ Text
Emergency Contact
- Name: ____________________________________
- Relationship: ______________________________
- Phone: (_) -
Insurance Information
Primary Insurance
- Insurance Company: __________________________
- Policy Number: _____________________________
- Group Number: _____________________________
- Policy Holder Name: ________________________
- Relationship to Patient: _____________________
Medical History
Current Medications
- _________________ Dosage: _______ Frequency: _______
- _________________ Dosage: _______ Frequency: _______
- _________________ Dosage: _______ Frequency: _______
Allergies
□ No Known Allergies
□ Yes (Please list): ____________________________
Previous Surgeries
- _________________ Date: //_____
- _________________ Date: //_____
Family History
- Heart Disease: □ Yes □ No Relation: _________
- Diabetes: □ Yes □ No Relation: _________
- Cancer: □ Yes □ No Relation: _________
- Other: ___________________________________
Authorization
I hereby authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to the physician.
Signature: ___________________ Date: //_____