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Name(Required)





Address(Required)















DD slash MM slash YYYY

Sex(Required)





Marital Status(Required)









Medical Insurance Information (Primary)

Name(Required)



More



Responsible Party Information (if other then patient)

Name(Required)





Address(Required)













DD slash MM slash YYYY

Sex(Required)





1 Emergency Contact

Name(Required)





2 Emergency Contact

Name(Required)





Medical Insurance Information (Secondary)

Name(Required)



Authorization to Pay Benefits to Physician



Patient Name(Required)





Gender(Required)







MM slash DD slash YYYY

Marital Status









Race(Required)













Ethnicity(Required)





Preferred Language(Required)























Retired?(Required)





Do you exercise regularly?(Required)





Any allergies to medication?(Required)





Substances (Please mark th following)

Caffeine(Required)







Tobacco(Required)







Alcohol(Required)







Medications (Please list your medications you are currently using)