1 Patient Demographics

step1

Required * If a required field below does not apply to you, please put NA

Date (ie MM/DD/YYYY)

Patient First Name * Patient Middle Initial * Patient Last Name *

Home Phone Number * Cell Phone Number * Work Phone Number * Email Address *

Mailing Address

Street Address * City * State * Zip Code *

Birthdate (ie MM/DD/YYYY) * Age *

Race * Ethnicity * Preferred Language *

Social Security Number * Employer * Spouse Name Spouse Social Security Number Spouse Employer

Emergency Contact * Phone number * Name of Primary Insurance Policy Number Relationship to Subscriber Secondary Insurance Subscriber D.O.B. (ie MM/DD/YYYY) Subscriber

If the patient is under the age of eighteen (18) years of age, the parent or legal guardian must fill out this section.

Parent or Legal Guardian Name Parent or Legal Guardian D.O.B( (ie MM/DD/YYYY)

Employement Parent or Legal Guardian Social Security Number

I hereby give authorization to SRHS Clinic Providers and staff to treat my minor child or myself. I hereby give authorization for payment of insurance benefits to be made to SRHS Clinics for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In case of default, I agree to pay all costs of collection and reasonable attorney’s fees. I hereby authorize this healthcare facility to release any and all information necessary to secure payment of benefits and that a photocopy of this agreement shall be as valid as the original.

I Agree *