Form Wmc 3116 – Fill Out and Use

Date of Initial Appointment: __________________________________

Patient Name: ____________________________________________

Date of Birth: _______________

SS#: ______-_____-______ Age: _______

Race: ______________ Sex: _____

Marital Status: ____________

Home Phone: (___) ___________

Cell Phone: (___) ___________

Other Contact number: (___) ___________

Email address (Optional): ________________________________________

Mailing Address: ________________________________

City: _________________

State: _____

Zip: ______

County: ________________________

Physical Living Address (If different from above): ____________________

City: __________ State: ___

Zip: ______

County: ________________________

Patient Employee: ___________________________________ Employer Phone: ____________________________

Employer Address: _____________________________

City: _________________

State: _____

Zip: _______

Emergency Contact Person

Primary: __________________________________________

Relationship: _____________________________

Phone: 1) Home: __________________

2) Work: __________________

3) Cell or other: __________________

Secondary Emergency Contact Person: ________________________ Relationship: _______________________

Phone: 1) Home: __________________

2) Work: __________________

3) Cell or other: __________________

Preferred language for health care information _________________________________________________________

INSURANCE DATA:

NOTE: You MUST bring valid insurance card to have claim submitted to Insurance Company.

Insurance Name: _______________________________________________________________________________

Subscriber Employer (if different from above): ________________________________________________________

Subscriber's Name: _____________________

Date of Birth: __________

Relationship to patient: ____________

If not on insurance card:

Policy #: ______________________________

Group #: _________________________

Claims mailing address: __________________________________________________________________________

Phone number for customer service: ______________________________________

Date of Birth: _____________

Guarantor Name, if other than patient: __________________________________

Guarantor's SS#: ______________

Guarantor's Address: ____________________________________________________________________________

Relationship to patient: ___________________________________________________________________________

Guarantor's Employer: ___________________________________________________________________________

Reason for your visit/diagnoses: ____________________________________________________________________

When did you start having these symptoms? __________________________________________________________

Referring Doctor's Name: _________________________________

Doctor's Phone Number: _________________

Family Physician: ________________________________________

ACCIDENT INFORMATION:

Were you in an auto accident?

Yes

No:

If yes, when and where (county or city) did the accident take place: ___________________________________

What is the name of the person responsible for the accident: ____________________________________________

What type of auto insurance does the responsible party have? __________________________________________

Did a Police or Sheriff come to the scene of the accident? ______________________________________________

Is this a work related accident:

Yes

No If yes, when did the accident happen? _______________________

Will you be filing a Liability Claim:

Yes

No If yes, please make sure this information is included in the insurance section of form.

Name of contact person for Worker's Compensation: ________________________ Phone number: ____________

Company's Name: ____________________________

Claim number for Worker's Comp: __________________

Patient's/Parent Signature: ___________________________________________

Date: __________________

Form may be thinned from Patient's File