Required Information is bolded.

Patient Name: (first name, middle initial, last name)

Date of Birth:
January February March April May June July August September October November December   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,   1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Gender:
Male Female

Note: your name, date of birth and gender will serve as temporary identification across the two forms you will complete. For security reasons you will be asked to re-enter them on the second form.

How do you prefer to be addressed by the doctor and staff?

Title:
Mr. Mrs. Ms. Miss Dr. Rev.

Street Address Line 1:

Street Address Line 2:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Social Security Number: (not required, but may be needed to file your insurance)

Marital Status:
Married Single Divorced Widowed

In case of emergency call:

Phone:

Whom can we thank for referring you to our practice?

EMPLOYMENT INFORMATION

(for insurance purposes only)

Occupation:

Employer Name: (please no abbreviations)

Employer Address Line 1:

Employer Address Line 2:

City:

State:

Zip:

SPOUSE OR PARENT EMPLOYMENT INFORMATION

Spouse or Parent's Name:

Relationship to Patient:

Occupation:

Employer Name: (please no abbreviations)

Employer Address Line 1:

Employer Address Line 2:

City:

State:

Zip:

If spouse or parent carries the insurance, please provide the following information:

Social Security Number: (not required, but may be needed to file your insurance)

Date of Birth:
January February March April May June July August September October November December   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,   1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Please note that the adult accompanying a minor (under the age of 18) is financially responsible for that patient, no exceptions.

Authorization: I have completed this form fully and completely and certify that I am the patient or duly authorized general agent of the patient authorized to furnish the information requested.

Payment: I understand that payment for professional services are the sole responsibility of the patient and are due as services are rendered. We do not render services on the basis that insurance companies will pay our fees, but we will be happy to assist you in filing claims for insurance reimbursement.