New Patient Form

Patient Information

Today's Date * +

Full Name *

Gender

Male

Female

Marital Status

Social Security #

Age

Date of Birth +

Email *

Address

City

State

ZIP Code

Home Phone #

Cell Phone #

Work Phone #

Race/Ethnicity

Language Spoken

Guardian of minor Name

Date of Birth +

Patient Employer

Employer Phone #

Emergency Contact Name

Emergency Phone #

Spouse Name

Spouse Employer

Mail order pharmacy name (if applicable)

Pharmacy Information

Local Pharmacy Name

City

Primary insurance name

Secondary insurance name

If policy holder of the insurance is different than the patient please complete:

Primary Insurance Information

Check if self-pay

Yes

Policy holder name

Date of birth +

Social Security #

Relationship to patient

Privacy Act and Medical Records Release for Insurance and Referring Physicians

I have reviewed the patient privacy act and understand that my records cannot be released without my written permission. I also authorize the release of all medical records to referring physicians and to my insurance company. I further authorize insurance payments to be made directly to premier Primary Care and understand that copays/patient balances are due at the time of service. I understand that I am responsible for a No-Show Fee of $50.00 if I do not call 24 hours in advance to cancel or reschedule my appointments.

Signature

clear

Date * +