Date

PATIENT INFORMATION

Date of Birth
Sex at Birth
Gender
Street Address

PARENT/LEGAL GUARDIAN INFORMATION

Legal Name
Street Address (if different from patient)

DISCLOSURE OF PERSONAL HEALTH INFORMATION

Additional adults authorized to receive health information pertaining to patient:
Legal Name

IN THE CASE OF A MINOR PATIENT

** If there are documents to prove medical decision-making authority or legal custody, please bring copies to your appointment to scan into the electronic medical record. **

INSURANCE INFORMATION

Policy Holder Name
Date of Birth
Policy Holder's Address (if different from above)

PREFERRED PHARMACY

CERTIFICATION OF INFORMATION

I hereby certify that the above information is true, correct, and complete in all respects.
Date