GENERAL INFORMATION

 PATIENT’S NAME
 D.O.B
 AGE
 GENDER
 MARITAL STATUS
 HOME PHONE
 MOBILE
 WORK PHONE
 ADDRESS
 CITY
 STATE
 ZIP
 PREF LANGUAGE
 ETHNICITY
 RACE
 EMERGENCY CONTACT ,( LAST NAME, FIRST NAME , PHONE NUMBER)
 OCUPATION
 DRIVERS LICENSE #
 SOCIAL SECURITY
 OCCUPATION
 EMAIL ADDRESS

PAST MEDICAL & SOCIAL HISTORY

 PREVIOUS ILLNESS
 SMOKE
 ALCOHOL
 ILLICIT DRUGS
 MEDICATION
 SURGERIES
 FAMILY HISTORY OF ILNESSES

ALLERGIES

 NONE
 DAIRY PRODUCTS
 SULFA DRUGS
 ADHESIVE TAPE
 IODINE/SHELLFISH/CONTRAST DYE
 WHEAT
 ANESTHESIA
 ASPIRIN
 LATEX
  MORPHINE
 CODEINE
 PENICILLIN
 OTHER

FOR WOMEN ONLY

 LAST PAP SMEAR

 LAST MENSTRUAL PERIOD
 LAST MAMMOGRAM

INSURANCE INFORMATION

 ISURANCE
 ID#
 ADDRESS
 POLICY GROUP
 EMPLOYER
 EMPLOYER PHONE
 INSURANCE POLICY HOLDER RELATIONSHIP
 PRIMARY DOCTOR
 CO-PAYMENT


FINANCIAL RESPONSIBILITY/CONDITION AND DISCLOSE OF INFORMATION

 I UNDERSTAND THAT PAYMENT OF MY BILL IS PART OF MY CARE,I HEREBY AUTHORIZE MY

ISURANCE BENEFITS BE PAID DIRECTLY TO THE PROVIDER AND I AM FINANCIALLY RESPONSIBLE
FOR NON-COVERED SERVICES:(DEDUCTIBLE,CO-PAYMENT,ETC). I AM AWARE THAT FORM OF
PAYMENTS IS CASH, DEBIT/CREDIT CARDS, CHECKS AND CARECREDIT AS A PAYMENT PLAN.

 I ALSO AUTHORIZE THE PROVIDER TO RELEASE ANY INFORMATION REQUIRED IN THE

PROCESSING OF THIS CLAIM AND ALL FUTURE CLAIMS.

 YOUR PROTECTED HEALTH INFORMATION WILL BE USED OR DISCLOSED BY OUR CLINIC TO

OTHERS FOR THE PURPOSE OF TREATMENT,OBTAINING PAYMENTS,PROVIDE A BETTER QUALITY
MEDICAL TREATMENT,AND OTHER PURPOSES ACCORDING TO HEALTH AND HUMAN SERVICES
AGENCIES’NOTICE OF PRIVACY PRACTICES IN TEXAS.

 SIGNATURE
  DATE

COMMUNICATING WITH PATIENT

 IN ORDER TO EFFECTIVELY COMMUNICATE WITH YOU REGARDING YOUR MEDICAL

INFORMATION, WE REQUEST THAT YOU COMPLETE THIS FORM TO INDICATE THE BEST WAY (S)
TO PROVIDE YOUR CONFIDENTIAL INFORMATION SUCH AS LAB RESULTS, RESPONDING TO
MESSAGE YOU LEFT FOR YOUR PROVIDER’S OFFICE OR PRECRIPTION INFORMATION.
INFORMATION MAY BE DELIVERED VIA PHONE, SECURE EMAIL MAIL, AND /OR LEAVING
MESSAGES ON YOUR VOICEMAIL.

 YOU MAY CONTACT ME BY PHONE ,PHONE NUMBER

 YOU MAY LEAVE A MESSAGE / VOICE MESSAGE
 YOU MAY CONTACT ME VIA EMAIL , EMAIL