General Intake Information
Patient Name
*
Patient Date of Birth
*
/
Month
/
Day
Year
Sex
Male
Female
Primary Address
*
Street Address
Apt. #
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Apt. #
City
State / Province
Postal / Zip Code
Phone Number to use FIRST to contact you
*
Is it ok to leave a detailed voice message?
*
Yes
No
Home Phone
Work Phone
Cell Phone
*
Email Address
Is there anyone you would like us to share your health information with?
Name
Relationship
Phone Number
Additional Information
Social Security Number
Occupation
Employer
Marital Status
Please Select
Married
Single
Divorced
Widow
Other
Other Marital Status (please type)
*
Spouse's Name
Spouse's Employer / Occupation
Emergency Contact
*
Emergency Contact Phone Number
*
Your Primary Care Physician
*
PCP Phone Number
*
Preferred Pharmacy
*
Pharmacy Phone Number
*
Insurance Information
Company Name
Company Group #
Company I.D. #
Company Address
Insured Name (if other than patient)
Insured's Social Security Number
Authorization
I hereby authorize Dr. Leo R. McCafferty to furnish information to insurance carriers and/or health care providers concerning this illness/accident, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not covered by insurance.
Signature
*
Q
K
Bundle
Current Date
/
Month
/
Day
Year
Date
Submit
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