NEW PATIENT INFORMATION SHEET: Name: (First) ________________________________ (MI)_______ (Last)____________________________________________________ Sex: ______________ Marital Drivers Date of Birth: / / Age:_______ Status:_________________ Social Security #:___________-_______-__________ License #:_________________________ Address: street___________________________________________________________city____________________________, state________, zip ______________________ Home phone number ( ) - Cell phone number ( ) - Email Address:_________________________________________ Work phone: ( ) - Employer:______________________________________________________________________________ Employer Address: street__________________________________________________ city___________________________, state________, zip:______________________ In an emergency contact:_______________________________________ relationship________________________ phone:( ) - If patient is a minor please complete the information below for the parent or guardian: Parent or legal guardian:___________________________________ relationship to patient:_________________________ social security number________-_____-________ Address: street_________________________________________________city:______________________________state: ____________ zip: ________________________ Date of Birth: / / Drivers License:___________________________________________________ Phone number: ( ) - Alternate number: ( ) - Work Phone: ( ) - Employer: _____________________________________________________________________________________________ Employer’s Address: street:_____________________________________________city:_________________________________ state: ____________ zip:_______________ INSURANCE INFORMATION: PRIMARY INSURANCE SECONDARY INSURANCE Insurance Company: _______________________________________________________________________________________________________________ Insurance ID #: __________________________________________________________________________________________________________________ Group #( if applicable): _____________________________________________________________________________________________________________ Policy Holder’s Name: ______________________________________________________________________________________________________________ Policy Holder’s address: _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Policy Holder’s phone #: ( ) - ( ) - Policy Holder’s relationship to patient: _________________________________________________________________________________________________ Policy Holder’s Employer: _____________________________________________________________________________________________________________ Employer’s Address: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Work phone number: ( ) - ( ) - Policy holder’s social security # ________________________________________________________________________________________________________ Newptinf.ppt 11/2015