PATIENT INFORMATION

Today's Date (mm/dd/yyyy):

Personal Information

First Name:Last Name:Middle Initial:
Permanent Address:
CityState/Province:Zip Code:
Country (if outside US):Phone 1:Phone 2:

Local Address If Different From
Permanent Address:
Local Phone 1:Local Phone 2:
City:State/Province:Zip Code:

Social Security Number:Sex:MaleFemale
Date Of Birth:Marital Status:MarriedSingleDivorcedWidowed
Employer:Employer Phone:
E-mail:
PharmacyPharmacy Phone:

Insurance Information (PLEASE PROVIDE ALL CURRENT INSURANCE CARDS AT REGISTRATION)

Primary Insurance Company:

Is this:MedicareMedicare HMOMedicaidPPOHMO

Other:Group Number:ID Number:

Secondary Insurance Company:

Is this:MedicareMedicare HMOMedicaidPPOHMO

Other:Group Number:ID Number:

Referral Information (PLEASE PROVIDE REFERRAL AT REGISTRATION)

Referring Physician:Referring Physician Phone #:
Primary Care Physician:PCP Phone #:

EMERGENCY CONTACT INFORMATION

Spouses/Significant Other Contact Information

Spouse's Full Name:
Spouse Address (if different):
City:State/Province:Zip Code:
Country (if outside US):
Home Phone:Cell Phone:Pager:
Spouse Occupation:
Spouse Employer:Spouse Work Phone:

Other Relative Emergency Contact

Name of Nearest Relative:
Relationship to Patient:
Home Phone:Work Phone:
Cell Phone:Pager: IN CASE OF EMERGENCY, I HEREBY AUTHORIZE YOU TO CONTACT THE FOLLOWING EMERGENCY CONTACT(S):

(Please check one or both)Spouse/Significant OtherOther Nearest Relative

PLEASE BE AWARE THAT IN CASE OF EMERGENCY, I HAVE COMPLETED THE FOLLOWING DOCUMENTS THAT I WILL PROVIDE TO THIS PHYSICIANS OFFICE WITHIN 10 DAYS OF SIGNATURE BELOW. I AM AWARE THAT MY REQUESTS CANNOT BE FOLLOWED UNLESS APPROPRIATELY SIGNED LEGAL DOCUMENTS ARE MAINTAINED IN THIS CHART OR PROVIDED AT THE TIME OF EMERGENCY.

Living WillDNR-Do Not Resuscitate


You may sign this when you come to the appointment



________________________________________________________________________________
Signature of PatientWitness Signature



________________________________________________________________________________
Patient NameWitness Name



Date___________________________________

LIFETIME INSURANCE AUTHORIZATION

I ________________________________________ authorize the release of any medical information


necessary to process my insurance claims. I request that all payments be made on my behalf, and that all benefits be assigned for physician services to


________________________________________ (Name of Physician's Group).


I authorize this request to apply to all services provided after the date below. I understand I am responsible for payment of any balance not paid by my insurance company as outlined in my schedule of benefits and as applicable under the law.


You may sign this when you come to the appointment


________________________________________________________________________________
Patient SignatureToday's Date



________________________________________
Name of Insured