New Patient Information Record (Form 1 of 5)

Please complete the fields below. If a field does not pertain to you, please put N/A.

Step 1 of 5

Patient Information
Name*
First Middle Initial Last
Social Security #*

ex. 000-00-0000
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Other Phone
work, mobile, etc.
Drivers License #*
Maiden Name
Date of Birth*

ex. 00/00/0000
Age*
Sex*
- Male
- Female
Marital Status*
- Single
- Married
Employment
Employer Employer Phone
Emergency Contact*
Name Phone

Insurance Information
Primary Insurance*
Insurance Company Name Insurance # Group #
Insured*
Insured Address*
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth*

ex. 00/00/0000
Sex*
- Male
- Female
Insured Employer*
Relationship of Patient to Insured*
Secondary Insurance
Insurance Company Name Insurance # Group #
Insured
Insured Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth

ex. 00/00/0000
Sex
- Male
- Female
Insured Employer
Relationship of Patient to Insured

Responsible Party
Fill out only if other than the patient.
Name
First Middle Initial Last
Social Security #

ex. 000-00-0000
Address
Street Address Address Line 2 City State ZIP Code
Phone
Date of Birth

ex. 00/00/0000
Sex
- Male
- Female
Relationship
Employer
Work Phone

Medical Information
Reason for Visit*
Drug Allergies*
List All Medicine Now Taking*
Other Medical Problems*
Previous Surgeries*
Surgery Year
Referred By*
Pharmacy*
Pharmacy Address*
Street Address Address Line 2 City State ZIP Code

Payment Policy*
I agree to the payment policy below
All professional services rendered are charged to the patient. The patient is responsible for payment regardless of insurance coverage. Full payment is expected at time of each office visit unless arrangements have been made in advance. Billing information will be provided to expedite patient reimbursement from private insurance carriers.
Authorization of Payment*
I agree to the authorization of payment
I hereby authorize the provider of services to release medical information concerning my examination and/or treatment for insurance purposes and to receive direct payment for medical benefits payable to me for services rendered.
Electronic Signature*

The parties agree that this form may be electronically signed. The parties agree that the typing their name in the signature box is the same as a hand written signature for purposes of validity, enforceability and admissibility.