New Patient Information Form - Template

New Patient Information

Please fill out this form. It will be very helpful if you have an image of your photo ID and Insurance Card(s). If you are filling this form out on a phone with a camera, you should be able to take a photo of each with your phone and attach them to this form.

ClinicEmail

Responsible Party

First Name*

Midde Initial

Last Name*

Social Security Number

Date of Birth*

Mailing Address*

Address Line 1

City

State

ZIP Code

Phone Number*

Relationship to Patient*

Employer’s Name

Work Phone Number

Extension

Responsible Party’s Spouse’s Name (if applicable)

First Name

Middle Name (optional)

Last Name

Responsible Party’s Spouse’s SSN (if applicable)

In Case of an Emergency

Who may we notify (other than someone living with you)?

Name*

First Name

Last Name

Relationship to Patient*

Date of Birth

Phone Number*

Address

Address Line 1

City

State

ZIP Code

Insurance Information

Is your Illness/injury due to an Auto/Work Accident*

Yes No

Insurance #1 Name of Insurance Company*

Insurance #1 Policy Number*

Insurance #1 Group Number*

Insurance #1 Employer

Insurance #1 Guarantor

Insurance #1 Photo of Front of Card

No File Chosen

File uploads may not work on some mobile devices.

Accepted image types include jpg, jpeg, gif, png, bmp, tif

Insurance #1 Photo of Back of Card

No File Chosen

File uploads may not work on some mobile devices.

Accepted image types include jpg, jpeg, gif, png, bmp, tif

Do You Have Additional Insurance Coverage?*

Yes No

Second Insurance Information

Insurance #2 Name of Insurance Company*

Insurance #2 Policy Number*

Insurance #2 Group Number*

Insurance #2 Employer

Insurance #2 Guarantor

Insurance #2 Photo of Front of Card

No File Chosen

File uploads may not work on some mobile devices.

Accepted image types include jpg, jpeg, gif, png, bmp, tif

Insurance #2 Photo of Back of Card

No File Chosen

File uploads may not work on some mobile devices.

Accepted image types include jpg, jpeg, gif, png, bmp, tif

Do You Have Additional Insurance Coverage (Third)?*

Yes No

Third Insurance Information

Insurance #3 Name of Insurance Company*

Insurance #3 Policy Number*

Insurance #3 Group Number*

Insurance #3 Employer

Insurance #3 Guarantor

Insurance #3 Photo of Front of Card

No File Chosen

File uploads may not work on some mobile devices.

Accepted image types include jpg, jpeg, gif, png, bmp, tif

Insurance #3 Photo of Back of Card

No File Chosen

File uploads may not work on some mobile devices.

Accepted image types include jpg, jpeg, gif, png, bmp, tif

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