Today's Date
Preferred Language
PATIENT INFORMATION
Patient Name
Is this your legal name?
Brith Date
Patient Middle Name
(For insurance purposes, please provide name as it is on social security card.)
Age
Patient Last Name
Marital status
Sex
Address
Zip code
City
State
County
Home Phone Number
Cell Phone Number
Email Address
Social Security Number
Race or Ethnicity
Occupation
Employer
Employer's Address
Employer's Phone Number
INSURANCE INFORMATION
Policy holder’s name
Policy holders’ phone number
Policy holder's address (if different)
Relationship
Policy holder's DOB
Policy holder’s employer
Policy holder's social security number
Please indicate primary insurance
Policy Number
Insurance phone number
Group Number
Insurance address
Please indicate secondary insurance
(if applicable)
Policy Number
Secondary insurance phone number
Group Number
Secondary insurance dddress
IN CASE OF EMERGENCY
Name of emergency contact
Relationship
Cell Phone Number
LIFETIME AUTHORIZATION
Preferred Payment Method
Electronic Signatures: Any signature hereto or to any other certificate, agreement or document related to this transaction, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary.
Patient / Guardian Signature
Date
CONTRACT FOR CARE
Electronic Signatures: Any signature hereto or to any other certificate, agreement or document related to this transaction, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary.
Patient / Guardian Signature
Date