Patient Information Form
Office Use Only / New / Existing / Account #:
***PLEASE PRINT ALL INFORMATION in BLACK/BLUE INK***
Patient Name: / Birth Date:Sex: / F / M / SS#: / Marital Status: / Single / Married / Divorced / Widowed / Other
Mailing Address:
Home Phone: / Cell Phone: / Other Phone:
May we remind you of appointment/lab needs via email? / No / Yes / Email:
Please select ethnicity: / I am not of Hispanic origin. / I am of Hispanic origin. / Do not wish to report
Preferred language: / English / Spanish / Other Language:
Please indicate one as your race: / Asian / Black, African American / Hispanic / Native Hawaiian
White / Other Pacific Islander / American Indian/Alaska Native / Do not wish to report
Employment Status: / Employed / Retired / Unemployed
Employer Name: / Work Phone:
Employer Address:
Occupation:
In emergency notify: / Phone #: / Relation:
Primary Care Physician: / Phone #:
Referring Physician: / Phone #:
PRIMARYInsurance Company:
Policy/Subscriber #: / Group #:
Policyholder Name: / Policyholder’s Birth Date:
Policyholder Employer Name/Phone#:
Policyholder’s relationship to patient: / Self / Spouse / Parent / Other:
SECONDARYInsurance Company:
Policy/Subscriber #: / Group #:
Policyholder Name: / Policyholder’s Birth Date:
Policyholder Employer Name/Phone#:
Policyholder’s relationship to patient: / Self / Spouse / Parent / Other:
IF THIRD INSURANCE, PLEASE LIST:
Name of Insurance: / Policyholder: / Policyholder’s DOB
Patient Signature (Guardian or Guarantor): / Date:
PLEASE BE READY TO PROVIDE AT THE FRONT DESK:
- Your insurance card(s) to be scanned
- Your driver’s license or ID to be scanned
- Your co-pay or payment due at time of service…
...and your best smile for a picture!
02/14/2013 Renal Common\Forms\NEW PT PKT 2013\Patient Information Form R1!