PATIENT INFORMATION


About the PATIENT

Date of Appointment: / /
Time of Appointment :
Physician:
Title
First Name
Initial
Last Name
Sex                            
Race                        
Other Ethnicity                        
Street Address
Apt./Suite#
City
State
Zip
Birthdate (xx/xx/xxxx) / /
Age
Marital Status
Home Phone ( ) -
Patient Cell Phone ( ) -
Patient Email Address
Referring MD        Physician Phone ( ) -
General Physician

       Physician Phone ( ) -


Name of Nearest Local Relative or Responsible Friend Who Can Be Contacted:


Relationship
Phone ( ) -

ADULT- Complete this section if the patient is an ADULT
Occupation
Employer
Employer Address
Business Phone ( ) - ext
Name of Spouse        Birthdate(xx/xx/xxxx)   / /

Employer                

Business Phone ( ) - ext
CHILD- Complete this section if the patient is a CHILD
Father's Name   Birthdate(xx/xx/xxxx)   / /
Father's Home Ph. ( ) -
Business Phone ( ) - ext
Father's Occupation  Employer
Mother's Name  Birthdate(xx/xx/xxxx)   / /
Mother's Home Ph. ( ) -
Business Phone ( ) - ext
Mother's Occupation  Employer
Pharmacy
Pharmacy Name
Phone Number ( ) -
Address/Location
Person Responsible For Bill
Name    Relationship

Address    City   State Zip
I authorize the Peachtree Allergy and Asthma Clinic, P.C. to furnish medical treatment, including injections and diagnostic tests, to me or my dependent, and I acknowledge instructions for follow-up care. I assign all insurance payments to Peachtree Allergy and Asthma Clinic, P.C.  I authorize the use of this form for all insurance submissions relating to myself or my dependents, and a photocopy of this authorization and assignment will be considered as valid as the original. I UNDERSTAND THAT I AM RESPONSIBLE FOR THIS BILL. By the signature below I acknowledge that I have read the above and agree to its content
Authorized Person   Date (xx/xx/xxxx) / /
I have been given the opportunity to review a copy of Peachtree Allergy and Asthma Clinic's Noticy of Privacy Practices containing a complete description of my rights to privacy and the uses and disclosures of health information.

Authorized Person   Date (xx/xx/xxxx) / /



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