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    New Patient Information Form Printable

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    Xyz
    This new patient information form collects demographic information such as name, address, phone numbers, email, date of birth, gender, race, ethnicity, language, insurance details, emergency contacts, and employment information from new patients of Vitae Family Care Clinic. It requests preferred methods of contact, pharmacy information, and authorization to share medical information with emergency contacts. The form notes that encrypted documents are required for secure email transmission of patient information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    New Patient Information Form Printable

    Uploaded by

    Xyz
    34 views3 pages
    This new patient information form collects demographic information such as name, address, phone numbers, email, date of birth, gender, race, ethnicity, language, insurance details, emergency contacts, and employment information from new patients of Vitae Family Care Clinic. It requests preferred methods of contact, pharmacy information, and authorization to share medical information with emergency contacts. The form notes that encrypted documents are required for secure email transmission of patient information.

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    New patient information printable form

    Original Title

    New-Patient-Information-Form-Printable

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    This new patient information form collects demographic information such as name, address, phone numbers, email, date of birth, gender, race, ethnicity, language, insurance details, emergency contacts, and employment information from new patients of Vitae Family Care Clinic. It requests preferred methods of contact, pharmacy information, and authorization to share medical information with emergency contacts. The form notes that encrypted documents are required for secure email transmission of patient information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    34 views3 pages

    New Patient Information Form Printable

    Uploaded by

    Xyz
    This new patient information form collects demographic information such as name, address, phone numbers, email, date of birth, gender, race, ethnicity, language, insurance details, emergency contacts, and employment information from new patients of Vitae Family Care Clinic. It requests preferred methods of contact, pharmacy information, and authorization to share medical information with emergency contacts. The form notes that encrypted documents are required for secure email transmission of patient information.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Vitae Family Care Clinic, LLC

    1355 50th St., Suite 100


    West Des Moines, IA 50266-1617
    Phone (515) 225.3261 | Fax (515) 225.1944

    NEW PATIENT INFORMATION FORM


    Patient Demographics
    Name:
    ______________________________________________________________________________________________________
    First Middle Last Maiden

    Primary Address:
    _____________________________________________________________________________________________
    Street Address City State
    Zip Code

    Phone Number: (_______) _______-_________ (_______) _______-_________ (_______) _______-


    _________
    Cell Home Work

    Email Address:
    ____________________________________@_________________________________________________________

    SS#: ______________________________________ Date of birth: ____/____/________

    PREFERRED METHOD OF CONTACT:_____________________________(i.e., e-mail, cell phone, home phone, work


    phone)

    Gender: □ Male □ Female

    Marital Status: □ Single □ Married □ Divorced □ Widow(er)

    Race: □ American Indian or Alaskan Native □ Asian □ Black or African American □ Native Hawaiian or other Pacific Islander
    □ White

    Ethnicity: □ Hispanic or Latino □ Not-Hispanic or Latino

    Language: □ English □ Spanish □ Other (please specify) __________________________

    How did you hear about our clinic?

    Primary Insurance
    Company: __________________________________
    ID#_______________________________PLAN#_________________

    Primary Co-pay Amount: $__________ Subscriber:


    _________________________DOB:__________________

    Secondary Insurance
    Company: __________________________________
    ID#_______________________________PLAN#_________________

    Primary Co-pay Amount: $__________ Subscriber:


    _________________________DOB:__________________

    Subscriber’s SSN: ____________________________ Subscriber’s Relation to Patient:


    _______________________________

    Responsible Party: ______________________________________________ Social Security#-


    ______________________________

    Address: __________________________________________City, State,


    Zip______________________________________________

    Relationship to patient: _________________________________


    TURN OVER

    Emergency Contacts
    Name:
    ______________________________________________________________________________________________________
    First Middle Last

    Phone Number: (_______) _______-_________ (_______) _______-_________ (_______) _______-


    _________
    Cell Home Work

    Relation to Patient: ___________________________ □ Yes I authorize this contact to make medical decisions on my
    behalf

    Name:
    ______________________________________________________________________________________________________
    First Middle Last

    Phone Number: (_______) _______-_________ (_______) _______-_________ (_______) _______-


    _________
    Cell Home Work

    Relation to Patient: ___________________________ □ Yes I authorize this contact to make medical decisions on my
    behalf

    **Preferred Pharmacy: Please fill out address**

    Name: ___________________________________________________ Phone Number: (_______) _______-


    _________
    Primary Address:
    _____________________________________________________________________________________________
    Street Address City State
    Zip Code

    Employment

    Occupation: _____________________________________ Employed Since: ____/____/________

    Employer: _______________________________________
    Only encrypted documents can be sent securely via email. To protect your privacy, please mail documents to the clinic or drop them off in person. A complete medical history will be taken on the day of your
    first visit.

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