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