Patient Information Form

Responsible Party Information
Responsible Party Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Sex
- Female
- male
Home Phone
Work Phone
Social Security Number
Responsible Party's Employer Information
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Authorization for Release of Medical Records
I authorize the release of my medical information including diagnosis, x-rays, test results, reports and records pertaining to any treatment or examination rendered to me. I understand that this medical information may be used for any of the following purposes: diagnostic, insurance, legal, and at times when necessary in order to ensure the best medical care on my behalf. I further understand that any person(s) that receives these medical records may further disclose this health information as needed to continue my care.
Patient or Parent / Guardian Signature (If Minor Child)
Date
MM slash DD slash YYYY

Spouse/Other Information