New Patient Form
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1
2
3Main Office
Satellite Office
2633 Dallas Parkway
2100 Hedgecoxe Rd
Suite 100
Suite 100
Plano, TX 75093
Plano, TX 75025
972-403-7733 phone
972-403-7744
fax
PATIENT INFORMATION
Patient name: _____________________________________________________________________________________
First
Middle
Last
Social Security #: _______________________
Sex: M F
Date of birth_____/_____/_____
Age ______
Home phone: (
) _________________ Cell phone: (
) ________________ Work phone: (
) _________________
Address:____________________________________________________E-mail ________________________________
Street
City
State
Zip
Job Title ___________________________________________________
Weight:______________
Shoe size:_________ Height____________
No, not Hispanic or Latino
What is your race? Please mark one or more.
White
Black or African-American
Asian
Hawaiian or other Pacific Islander
American Indian or Alaska Native
What is your Primary Language? __________________________________________
____________
Primary doctor: ________________ Phone #:_______________ Pharmacy:
Phone #:_____________
Are you currently in a skilled nursing facility, rehab, or long term care facility?
No
Name of facility____________________________ Address of facility_________________________________________
Do home health nurses visit you?
Name of the home health company?_______________________________
How did you hear about Dr. Graff?______________________________________________________________________
SPOUSE/PARENT/GUARANTOR INFORMATION
Name: __________________________________________________________________________________________
First
Middle
Last
Home phone: (
) ______________ Cell phone: (
) ______________ Work phone: (
) ______________
INSURANCE INFORMATION
INSURANCE COMPANY: ____________________________ Policy#: ____________________ Group #:____________
Policy holder name: _______________________________ DOB:____________ Social Security #: ___________________
SECONDARY INSURANCE: _________________________ Policy#: ____________________ Group #:_____________
Policy holder name: ______________________________ DOB:____________ Social Security #: ____________________
EMERGENCY CONTACT
Name: ____________________________________Relationship__________ Home: _______________ Cell: ________________
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Parent category: Medical