706 613 6650

New Patient Form

Page 1

Name
First:
Last:
Middle Initial:
Address
Street:
Apartment #:
City:
State:
Zip:
Telephone
Home:
Work:
Cell:
Ext.:
Personal Information
Email Address:
Date of Birth (mm/dd/yyyy):
Martial Status:
Single Married Divorced Widowed
Employer:
Occupation:
Emergency Contact Information
Name:
Home Phone:
Work Phone:
Relation:
Cell Phone:
Extension:
Spouse/Parent Contact Information
Name:
Employer:
Home Phone:
Work Phone:
Extension:
Occupation:
Cell Phone:
Primary Care Physician
Please enter the name of your primary care physician:
Referring Source
Who can we thank for referring you to us?:
Other Source:

Consent for Disclosure to Family Members or Personal Representative

I have agreed to let certain individuals participate in discussion and decisions related to my medical care. Therefore, I hereby give my permission to Dr. Cesar Gumucio and their staff to disclose my personal medical and financial information to the following individuals(s). This includes discussion of account information, making of appointments, prescription concerns, etc.
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Conditions for Disclosure
I understand that this consent is in effect until revoked by me with written notice to the practice. I also understand if I have any questions about the privacy of my health information that I can discuss them with the office staff at any time.
(check the item(s) that apply):
The practice may disclose information to the individual(s) only in my presence.
The practice may disclose information to the individual(s) above in discussions in my presence and when I am not physically present, including disclosure by telephone, facsimile or email.
Other:

Insurance Information

Primary Insurance Information
Policyholder:
DOB:
Policy # or ID #:
  
Relationship to Patient:
Self Spouse Parent
Primary Insurance Company
Name:
Phone:
Street:
City:
State:
Zip:
Secondary Insurance Information
Policyholder:
Policy # or ID #:
DOB:
  
Relationship to Patient:
Self Spouse Parent
Secondary Insurance Company
Name:
Phone:
Street:
City:
State:
Zip:
Is this workman's compensation?:
Yes    No    		  
I would be interested in receiving these updates via email.