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Patient Demographic Form

KELVIN YEH, MD

723 S. Garfield Ave, Ste. 202
Alhambra, CA 91801

Phone:
(626) 872-1553
Fax:
(844) 829-2399

PATIENT INFORMATION

Last Name

First Name

Mid.Initial

Date of Birth

Gender

Male Female

Social Security #

Home Phone #

Cell Phone #

Email
Marital Status: Single Married Divorced Separated Widowed Other

Home Address

City

State

Zip

Employer

Phone #

  

EMERGENCY CONTACT INFORMATION

Last Name

First Name

Phone #

Relationship to patient

PHARMACY INFORMATION

Name of Pharmacy

Phone #

Address

City

State

Zip

INSURANCE INFORMATION

Primary Insurance Provider

Policy Number

Group Number

Secondary Insurance Provider (if applicable)

Policy Number

Group Number

PHYSICIAN REFERRAL INFORMATION

Primary Care Physician

Phone #

Referring Physician

Phone #

How did you hear about us

Employer Family Member Yellow Pages Friend Insurance
Other: Doctor:
ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITIES: This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for the service rendered, including reasonable attorney's fee and costs of collection in the even of default. I further understand that if payment becomes 30 days past due, delinquency charges at the lesser of the annual rate of 12%, or the maximum allowable will be due on delinquent from the rate of payment was due. Insurance co-pay will be collected according to my insurance plan at the time of visit.
DISCLAIMER: BY SIGNING THIS FORM, YOU ACKNOWLEDGE AND CONSENT THAT YOUR ELECTRONIC SIGNATURE HOLDS THE SAME LEGAL VALIDITY AS YOUR HANDWRITTEN SIGNATURE ON THIS APPLICATION.

Signature

Date: