CANADIAN, TX 79014

NAME ________________________________ BIRTHDATE ____________________ AGE ____________

SOCIAL SECURITY # _______ ______ _________ PHONE # __________________ SEX ____________

ADDRESS ____________________________ CITY ___________________________ ZIP _____________

MARITAL STATUS: SINGLE ________ MARRIED _________ WIDOWED _________

FAMILY MEMBERS LIVING IN HOUSEHOLD:

NAME _____________________________ BIRTHDATE _____________ RELATION ___________________

EMPLOYER _____________________________________ PHONE # _______________________________

ADDRESS ______________________________________ CITY _____________________ ZIP __________

RESPONSIBLE PARTY _________________________________ PHONE # ______________________

ADDRESS ____________________________________ CITY _____________________ ZIP ____________

PHARMACY OF CHOICE: _________________________________________ PHONE # __________________

EMERGENCY CONTACT: _________________________________________ PHONE # __________________

INSURANCE CO. ______________________________________________________________ COPY Y / N

SUPPLEMENTAL INSURANCE: __________________________________________________ COPY Y / N

WE REQUEST A COPY OF YOUR INSURANCE CARD TO ENABLE US TO FILE WITH YOUR INSURANCE COMPANY. PLEASE NOTE THAT YOUR INSURANCE CONTRACT IS BETWEEN YOU AND YOUR INSURANCE COMPANY. WE WILL ASSIST YOU IN FILING YOUR CLAIM HOWEVER WE CANNOT BE LIABLE FOR THE COLLECTING OF YOUR CLAIM THEREFORE YOU WILL BE RESPONSIBLE FOR THE UNPAID BALANCE OF YOUR BILL.

AUTHORIZATION OF BENEFITS:

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO HEMPHILL COUNTY CLINIC

SIGNATURE: _________________________________________________________________

RELEASE OF INFORMATION:

I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM.

SIGNATURE: _________________________________________________________________

CONSENT

I UNDERSTAND THAT MY TREATMENT(S) AS AN OUTPATIENT IN THIS HEALTH FACILITY IS INDICATED BECAUSE OF MY CONDITION. I VOLUNTARILY AUTHORIZE AND CONSENT TO THE USUAL AND CUSTOMARY EXAMS, TESTS AND PROCEDURES PERFORMED BY HEMPHILL COUNTY CLINIC AND STAFF.

SIGNATURE: _________________________________________________________________

MEDICAL INFORMATION

ARE YOU ALLERGIC TO ANY MEDICATIONS? YES ____________ NO _____________

IF YOU ANSWERED YES, PLEASE LIST _________________________ __________________________

_________________________________ __________________________ ___________________________

PLEASE LIST ALL MEDICATIONS THAT YOU ARE NOW TAKING:

NAME _______________________________ STRENGTH _______________ HOW OFTEN ______________

NAME ______________________________ STRENGTH _______________ HOW OFTEN ______________

DO YOUR HAVE ANY HISTORY OF LONG TIME ILLNESSES? PLEASE LIST:

____________________________ ____________________________ _____________________________

DOES ANY MEMBER OF YOUR FAMILY HAVE A HISTORY OF DIABETES, HIGH BLOOD PRESSURE, CANCER, ETC.? IF YOUR ANSWER IS YES PLEASE LIST:

ILLNESS _____________________________________ RELATIONSHIP _______________________________

ARE YOU CURRENTLY BEING TREATED BY ANOTHER PHYSICIAN?

IF YOUR ANSWER IS YES, MAY WE PLEASE ASK WHAT YOU ARE BEING TREATED FOR AND BY WHOM:

DR: ________________________________________ ADDRESS _____________________________________

REASON __________________________________________________________________________________

WHEN WAS YOUR LAST COMPLETE HEALTH EXAM: ____________________________________________

I AGREE THAT THIS HISTORY IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE __________________________________________________ DATE _______________________