APPOINTMENT DATE: PATIENT INFORMATION Last Name: First Name: Middle: Maiden Name: Date of Birth: Sex: Male Female Other Social Security #: Marital Status: Driver’s License #: Primary Language: Race: DECLINED Caucasian/White African/American/Black American Indian Asian Other Race Ethnicity: DECLINED Hispanic or Latino Not Hispanic or Latino Pharmacy: Pharmacy Address: Pharmacy Telephone: Home Address: Apt #: City #: StateALAKARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNENHNJNMNVNYNDOHOKORPARISCSDTNTXUTVTVAWAWIWVWY Zip Code: Home phone: Work phone: Cell phone: Email: Employer name: Address: Occupation: Emergency contact name: Phone: Relationship: REFERRING DOCTOR INFORMATION Who referred you to this office? Phone: Who is your primary doctor (if different)? Phone: INSURANCE INFORMATION PRIMARY INSURANCE NAME: Policy #: Group #: CLaims Address: Policyholder name: Relationship to you: Policyholder social security #: Date of Birth: Sex: Male Female Other SECONDARY INSURANCE NAME: Policy #: Group #: CLaims Address: Policyholder name: Relationship to you: Policyholder social security #: Date of Birth: Sex: Male Female Other PLEASE READ & SIGN: I understand that it is my responsibility to pay any applicable co-payments, deductibles, co-insurance, and any other balance not paid for by insurance. I understand that it is my responsibility to obtain a valid referral, if applicable, for all visits and if any claim is denied for no referral then I may be responsible for payment. I understand that it is my responsibility to advise the practice of any changes to any of the above information and if any claim is denied as a result of not advising the practice then I may be responsible for payment. I hereby authorize the doctor and/or the practice to release all information necessary to secure the payment of benefits. I authorize and assign all benefits to be paid directly to the practice. I agree that a photocopy of this agreement shall be as valid as the original. PLEASE READ & SIGN:I understand that it is my responsibility to pay any applicable co-payments, deductibles, co-insurance, and any other balance not paid for by insurance. I understand that it is my responsibility to obtain a valid referral, if applicable, for all visits and if any claim is denied for no referral then I may be responsible for payment. I understand that it is my responsibility to advise the practice of any changes to any of the above information and if any claim is denied as a result of not advising the practice then I may be responsible for payment. I hereby authorize the doctor and/or the practice to release all information necessary to secure the payment of benefits. I authorize and assign all benefits to be paid directly to the practice. I agree that a photocopy of this agreement shall be as valid as the original. PATIENT SIGNATURE: DATE: