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
*
Format: (000) 000-0000.
Is it ok to leave a detailed voice message?
*
Yes
No
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Email Address
Is there anyone you would like us to share your health information with?
Name
Relationship
Phone Number
Format: (000) 000-0000.
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
*
Format: (000) 000-0000.
Your Primary Care Physician
*
PCP Phone Number
*
Format: (000) 000-0000.
Preferred Pharmacy
*
Pharmacy Phone Number
*
Format: (000) 000-0000.
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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