Patient Intake by wFjZG2m



Name:_________________________________________ Date of Birth:____________________________ M or F

SSN:___________________________ Address: ___________________________________________________________

City:______________________________________ State:__________ Zip:_____________________________________

Phone: (     )___________________ Cell phone: (             ) _________________________ Work: __________________

Marital Status: S M D W          Email: ___________________________________________________________________

Would you like to be web enabled to view your medical records?            Y   N

Employer: ____________________________________________ Employer phone: _______________________________

Race: Caucasian            African American           Hispanic          Other          Ethnicity:   Non-Hispanic      Hispanic

Emergency Contact Name/Relationship/Phone: ____________________________________________________________

Name of Parent(s) (for minors):_________________________________________Phone:___________________________

Preferred Pharmacy Name:____________________________________________Phone:___________________________

INSURANCE INFORMATION: (IF SELF, SKIP THIS SECTION)              Insurance:________________________________________

Person responsible for bill/insurance holder: ______________________________________________________________

Insurance holder: Date of Birth:_________________________                 Relationship to subscriber: Spouse Child Other

SECONDARY INSURANCE? Y N (please fill in same information on line below).



May we leave messages at contact numbers? Y N           May we include test results in messages: Y N

Name of other person(s) we may also speak to:____________________________________________________________


_______ Patient with Insurance: You are responsible for deductibles, co-pays, non-covered services, coinsurance, and items
considered not medically necessary by your insurance company. Copays and deductibles are due at the time of service. Any
remaining balances should be taken care of within one month of notice from your insurance company. If payments cannot be made
at each visit, notify the front desk to make other payment arrangements.

_______ Medicare/Medicaid: You are responsible for any deductibles, copays, and coinsurance amounts that are not covered by
your primary or secondary insurance plans. The remaining balance should be taken care of immediately after hearing from your
insurance company unless arrangements have been made.

________ Self-Pay: You are responsible for services at the time they are rendered to you. If you are not able to pay your bill in full,
then you will need to make payment arrangements before you leave the office at each visit. A payment will need to be made each

Please note that your account may be assessed a finance charge if we need to process more than one statement per visit.

Signature:_____________________________________________________ Date:________________________________________

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