Patient Information Sheet
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1Patient Information Sheet
Patient Name:(First)
______________
_____(Last)
______________________(Middle)_____________________
DATE OF BIRTH:___________________________________
Email Address:(Optional)_________________________________
Patient Address:
Home Telephone #:
Home Address:___________________________________________
Cell #:_______________________________________
City:_______________________________
State:________ Zip Code:____________Emergency Number #:____
Emergency Name/Relation:________________________________
Social Security#:_____________________________________
Sex (Circle one): Male
Female
Marital Status (Circle one): Married
Single
Other
Primary Care Physician:
Referring Physician:
Patient’s Employer:
Employer’s Phone Number:
Employers Address:
How were you referred to this office?_____________________________________________________________________________
List any relatives that are patients here:___________________________________________________________________________
_______________
Responsible Party’s Name:(if under age 18)
Relation to Patient:______________
Security Number:________________ ___ _____
Sex:
M /
F
Birth Date:____________ _______________
Responsible Party’s Address:
Responsible Party’s Phone #:__________________________
City:
State:_________________
__
Zip Code:______________________________
Responsible Party’s Employer:_____
Employer’s Phone#:
Employer’s Address:
________
Primary Insurance:____
_Patient’s Relationship to Insured:
____________________________
Are you the primary insured for your policy?
Y / N IF NO, Insured’s Name:__________________________________________
Insured’s Name:
_________
_______________
Insured’s DOB:_____
Address:
Insured’s Sex:
Male
Female
City:
___________
State:
Zip Code:
Insured’s SSN:
Insured’s Employer:
__
Employer’s Phone:_________________________________________
Employer’s Address:________________________________ City:_________________________ST:_________Zip Code:___________
_________
Secondary Insurance:____
_Patient’s Relationship to Insured:
____________________________
Are you the primary insured for your policy?
Y / N IF NO, Insured’s Name:__________________________________________
Insured’s Name:
_________
_______________
Insured’s DOB:_____
Address:
Insured’s Sex:
Male
Female
City:
___________
State:
Zip Code:
Insured’s SSN:
Insured’s Employer:
__
Employer’s Phone:_________________________________________
Employer’s Address:________________________________ City:_________________________ST:_________Zip Code:___________
________
**Please inform us if you have a third insurance**
____________________________________________________________
I hereby authorize Piedmont HealthCare to release information concerning my medical or surgical treatment to any insurance
carrier, including Medicare and Medicaid. I further authorize payment being made directly to Piedmont HealthCare for my
insurance benefits including major medical insurance. I understand that I am financially responsible to Piedmont HealthCare for my
charges and that the filing of insurance does not relieve me of this obligation. I further authorize any payment made by insurance
companies that are incorrect to be refunded to the insurance company. I consent to x-ray examinations, laboratory procedures and
other medical treatment as recommended by my physician as provided by authorized personnel of Piedmont HealthCare. I also
understand that Piedmont HealthCare is not responsible for any of my personal or valuable items I bring with me.
Signature (seal)
Date:
Information Verified by:
Date:
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Parent category: Medical