First:
*
Middle:
Patient's last name:
*
Is this your legal name?
Yes
No
If not, what is your legal name?
*
(Former name):
Mr.
Mrs.
Miss
Ms.
Marital Status
Single
Married
Divorced
Separated
Widowed
Birth date:
*
/
Month
/
Day
Year
Date
Age:
Sex:
*
M
F
Phone no.:
*
Street address:
*
P.O. Box:
City:
*
State:
*
ZIP Code:
*
Employer:
Employer phone no.:
Occupation:
Chose clinic because/Referred to clinic by (please check one box):
Family
Friend
Close to home/work
Yellow pages
Insurance Plan
Hospital
Insurance Subscriber's name:
*
Date of Birth of Subscriber
*
Name of Primary Insurance:
*
Policy Number:
*
Group number:
Patients's Relationship to Subscriber
*
Self
Spouse
Child
Name of secondary insurance (if applicable):
Subscriber's Name
Policy Number
Group Number
Patient's Relationship to Subscriber
Self
Spouse
Child
In case of Emergency:
*
Name
Relationship to Patient
*
Home phone no.:
*
Work phone no.:
Date
*
/
Month
/
Day
Year
Date
Signature
*
Clear
Patient/Responsible Party Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
Signature of Patient or Legal Guardian
*
Clear
Printed Name of Patient or Legal Guardian
*
Date
*
/
Month
/
Day
Year
Date
Would you like to give us permission to speak to anyone about your healthcare, appointments etc.? If so, type their name here, or type none.
Signature of Patient or Legal Guardian
*
Clear
Relationship to Patient
*
Print Patient's Name
*
Date
*
/
Month
/
Day
Year
Date
Print Name of Patient or Legal Guardian, if applicable
B. Patient's Name:
*
Type your Initials Here
*
Choose one of these options
*
I would like insurance to cover all services performed by New Path Medical Center
I do NOT want my insurance to cover any services performed by New Path Medical Center, and I may be responsible for any charges incurred.
I do not want to be seen at New Path Medical Center
I. Signature:
*
Clear
J. Date:
*
/
Month
/
Day
Year
Date
Patient Name
*
Patient's Signature
*
Clear
Date
*
/
Month
/
Day
Year
Date
Parent or Guardian Signature (for children under 18)
Clear
Date
*
Print name
*
Submit
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