Patient Demographic Form

PATIENT INFORMATION

Last Name:

First Name:

Mid.Initial:

Date of Birth:

Gender:

Social Security #

Email:

Home Phone #

Cell Phone #

Home Address:

State:

City:

Zip:

Employer:

Phone #

EMERGENCY CONTACT INFORMATION

Last Name:

First Name:

Phone #

Relationship to patient:

PHARMACY INFORMATION

Name of Pharmacy:

Phone #

Address:

State:

City:

Zip:

INSURANCE INFORMATION

Primary Insurance Provider:

Policy Number:

Group Number:

PHYSICIAN REFERRAL INFORMATION

Primary Care Physician:

Phone #

Referring Physician:

Phone #

How did you hear about us?

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:

KELVIN YEH, MD

Patient Demographic Form

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

PHARMACY INFORMATION

INSURANCE INFORMATION

PHYSICIAN REFERRAL INFORMATION