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Patient Information Name:
Address:

State:
Zip:
SSN: - -
Birth Date:
Home Phone: () -
Employer:
Work Phone: () -
Marital Status: Married Single Divorced Widowed

Are you a full-time student? Yes

Responsible Party Information

All of the following questions pertain to the insured party responsible for charges related to the patient's visit.

Name:
Address:

State:
Zip:
SSN: - -
Date:
Home Phone: () -
Employer:
Work Phone: () -
Email:
Relationship to Patient:
Insurance Carrier:
Group Number:
Policy Number:
Effective Date:

Secondary Insurance

Please provide the following information for any secondary insurance policies that should be filed.

Insured Name:
Relationship to Patient:
Insurance Carrier:
Group Number:
Policy Number:
Effective Date:

Personal Information Gender:
Height: ft. in.
Weight: pounds
Allergies / Reactions: Medication Food Latex Other

Does the patient have or ever had:

Heart Problems (Congestive Heart Failure, Chest Pain, Murmur, Irregular Heart Beat,Heart Attack, Rheumatic Fever, Ankle Swelling, Etc.)
High or Low Blood Pressure
Lung Problems (Asthma, Emphysema, COPD, Tuberculosis)
Neurologic Problems (Seizure, Stroke)
Diabetes
Hypoglycemia (Low Blood Sugar)
Kidney Problems
Thyroid Problems
Liver Problems (Hepatitis, Jaundice)
Acid Reflux / Esophageal Disease
Bleeding Problems or take blood thinners
Problems with Anesthesia (You or any member of your family)
Smoking/ Tobacco Use
Do you wear contact lenses?

Communication Needs: Vision Hearing Language Speech

Do you have any physical limitations? Yes

Do you take any medications or over-the-counter meds? Yes

Do you take any vitamins, herbal or "alternative" medications? Yes

Have you ever had surgery before?Yes

I agree that the information provided is truthful and accurate.

I Agree