New Patient Package Forms

h4>Form 1 of 7

Is the patient a minor?
- Yes
- No
Patient Name*
First Middle Last
Parent/Guardian or Responsible Party Name
First Middle Last
Patient Date of Birth*
Parent/Guardian or Responsible Party Name Date of Birth
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Cell Phone*
Work Phone
Patient SSN Last 4 Digits*
Parent/Guardian or Responsible Party SSN
Race:*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Decline to Specify
Ethnicity*
- Hispanic or Latino or Spanish Origin
- Not Hispanic or Latino or Spanish Origin
- Decline to Specify
Email
Pharmacy*
Pharmacy Phone*
- Occupation or Prior Occupation (If retired)
- Employer
- Marital Status
  - Single
  - Married
  - Divorced
  - Widowed
- Spouse's Name
- Spouse DOB
- Spouse Phone Number
Emergency Contact (Other than spouse)*
Emergency Contact Phone Number*
Primary Insurance
- HMO
- PPO
- None
Name of Primary Insurance
Name of Secondary Insurance
- Name of Referring Physician
- Do you have a Primary Care Physician?*
  - Yes
  - No
- Please list Primary Physician
Please list all other physicians you see (cardiology, pulmonology, nephrology, etc.)
Do you have a living will or advance directive?
- Yes
- No
Is this appointment related to a Workman’s Compensation case?*
- Yes
- No
Is this appointment the result of a motor vehicle accident?*
- Yes
- No
PLEASE GIVE YOUR INSURANCE CARDS/LIVING WILL/ADVANCE DIRECTIVE/PHOTO ID TO THE RECEPTIONIST SO THAT WE CAN MAKE A COPY FOR YOUR FILE
I certify that any information given by me is correct and hereby authorize direct payment of benefits to Jose A. Gaudier, MD, PA for services rendered by my physician in person or any of his partners or under his/their supervision and understand that I am financially responsible for any balance not covered by my insurance company. In addition, I authorize the release of any medical or incidental information that may be necessary for either medical care or in processing application for financial benefit.
Date
Patient Signature*
Parent/Guardian or Responsible Party Signature

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