Silver Sage Center New Patient Form

Patient Information

Name

First Last

Home Phone

Cell Phone

Work Phone

Email

Patient Social Security #

Date of Birth

Gender

Male
Female

Marital Status

Physical Address

Street Address City State ZIP Code

Mailing address is different than physical address.

Yes
No

Mailing Address

Street Address City State ZIP Code

Do you require a language translator?

Yes
No

What language?

Are you visually impaired?

Yes
No

Are you hearing impaired and require a sign language translator?

Yes
No

If not, can we communicate via paper?

Yes
No

Emergency Contact

Name

First Last

Phone

Relationship

Patient or Parent Employment Information

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

Name of Employee

First Last

Occupation

Insured Social Security #

Work Phone

Insurance Information

Name of Subscriber

First Last

Realtionship to Patient

Birthdate of Subscriber

Social Security #

Name of Employer

Work Phone

Insurance Company

Policy Number

Group Number

Secondary Insurance

Subscriber Name

First Last

Birthdate of Subscriber

Relationship to Patient

Employer

*

I understand that co-payments are due at time of visit. I authorize payment of medical benefits from my insurance company to Silver Sage Center for Family Medicine. I also authorize the release of any medical information necessary to process any medical claim. I realize that I am responsible for any balance my insurance company does not cover/pay. I acknowledge receipt of the privacy policies and practices notice.

Disclosure

We can not release ANY information to any one else but the patient without written permission from the patients.

Is there a friend or family member whom we may disclose your medical information?

First Last

What is there relationship to you?

Signature

We do not discriminate against anyone regardless of color, race or creed or physical ability.

What is the best means to contact you?

Signature*

Date*

Signature*

By checking this box, I am agreeing that this information is being submitted digitally via the web, and will serve as an acceptance in place for my signature.

Silver Sage Center Patient Information Sheet

Patient Information

Emergency Contact

Patient or Parent Employment Information

Insurance Information

Disclosure

Signature

Silver Sage Center for Family Medicine

Directions

Silver Sage Sports & Fitness Lab