1. 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 ( ) 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