Patient Name:
    Prefered Name:
    Date of Birth:
    Sex:
    Cell Phone:
    Work Phone:
    Address:
    City:
    State:
    ZIP:
    Driver's License Number:
    Appointment Availability (days): Appointment Availability (time):
    Father's Name:
    Father's DOB:
    Home Phone:
    Cell Phone:
    Work Phone:
    Mother's Name:
    Mother's DOB:
    Home Phone:
    Cell Phone:
    Work Phone:
    Emergency Contact:
    Emergency Contact Phone:
    Best time to contact me: Best way to reach me: Choose appropriate option for patient: If student,
    Name of School:
    City/State:
    Does the child receive therapy services in the school system? Has the child received therapy services at another clinic?
    Primary Physician Name:
    Primary Physician Number:
    Referring Physician Name:
    Referring Physician Number:
    Insurance Information Relationship to Patient
    Name:
    Phone:
    Address:
    City:
    State:
    ZIP:
    Email Address:
    Social Security Number:
    Employer:
    Primary Insurance
    Name of Policy Holder:
    DOB:
    Name of Employer:
    Work Phone:
    Insurance Company:
    ID Number:
    Group Number:
    Insurance Company Address:
    City:
    State:
    ZIP:
    Insurance Company Phone:
    If you have any additional insurance, please complete the following secondary insurance information. Secondary Insurance
    Name of Policy Holder:
    DOB:
    Name of Employer:
    Work Phone:
    Insurance Company:
    ID Number:
    Group Number:
    Insurance Company Address:
    City:
    State:
    ZIP:
    Insurance Company Phone:
    I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. If for any reason any portion is not paid for by my insurance, I agree to make arrangements for prompt payments of the account. I have read all the above information and completed the above answers truthfully and correctly. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status regarding the above information.
    Date:

    Document(s):

    Patient Information