Carter-Hargrove, Inc.

NEW Patient
Information
www.carterhargroveinc.com

PATIENT INFORMATION
NAME: ______________________________________________________ DATE OF BIRTH: ____________________ SS#: _______________________

ADDRESS: __________________________________________________ CITY: ________________________________ ZIP CODE: _________________

HOME PHONE: ______________________________________________ CELL PHONE : _____________________________________________________

EMAIL ADDRESS: _______________________________________________________________________________________________________________

AGE: ____________ GENDER (circle):: MALE FEMALE MARITAL STATUS (circle): Single Married Divorced Widowed Remarried

SPOUSE NAME: _______________________________________________ DATE OF BIRTH: ____________________ SS#: _______________________

NAME OF REFERRING PARTY: _____________________________ REFERRING PARTY IS (circle): Physician Clergy Friend Other
IF PATIENT IS A MINOR:
NAME OF: PARENT
GUARDIAN
___________________________________________________________________________________________________________
EMPLOYMENT:
PATIENT'S EMPLOYER NAME: ________________________________________________PHONE: (_____) ________________

EMPLOYER'S ADDRESS: __________________________________________________________________________________

PAYMENT INFORMATION:
PAYMENT FOR SERVICES WILL BE MADE WITH:
CASH CHECK INSURANCE
PRIMARY INSURANCE INFORMATION
PATIENT'S INSURANCE IS PROVIDED BY?
YOURSELF EMPLOYER _____________________________________ YOURSELF EMPLOYER _____________________________________
PRIMARY CARE PHYSICIAN: ___________________________________________
INS. CO. NAME: ______________________________________________________
ADDRESS: __________________________________________________________
CITY: ___________________________ STATE: ____________ ZIP:____________
INS. CO. TEL#: _______________________________________________________
YOUR I.D. NO.: _______________________________________________________
GROUP I.D. NO.: ______________________________________________________
YEARLY DEDUCTIBLE AMOUNT: $ ______________________________________
CO-PAYMENT % or AMOUNT: $ _________________________________________
SECONDARY INSURANCE INFORMATION
PATIENT'S INSURANCE IS PROVIDED BY?
PRIMARY CARE PHYSICIAN: ___________________________________________
INS. CO. NAME: ______________________________________________________
ADDRESS: __________________________________________________________
CITY: ___________________________ STATE: ____________ ZIP:____________
INS. CO. TEL#: _______________________________________________________
YOUR I.D. NO.: _______________________________________________________
GROUP I.D. NO.: ______________________________________________________
YEARLY DEDUCTIBLE AMOUNT: $ ______________________________________
CO-PAYMENT % or AMOUNT: $ _________________________________________

Date: __________________________ Signature: ______________________________________________

924 Pyramid Way, Sparks, Nevada 89431-4442 775.771.1010 775.448.6161 DrH@CarterHargroveInc.com