new patient information form - Central Florida Pain and Rehab Clinic

new patient information form - Central Florida Pain and Rehab Clinic

NEW PATIENT INFORMATION FORM
PATIENT INFORMATION/INFORMACION DEL PACIENTE
NAME/NOMBRE
__________________________________________________
DOB/FECHA NACIMIENTO
SOCIAL SECURITY/SEGURO SOCIAL
______________________________________________
MARITAL STATUS/ESTADO CIVIL
( ) SINGLE/SOLTERO
RACE/RAZA (OPTIONAL)
( ) HISPANIC/HISPANO
( ) WHITE/BLANCO
ETHNICITY/ETNIA
( ) HISPANIC OR LATINO/HISPANO O LATINO
LANGUAGE/IDIOMA
( ) ENGLISH
( ) MARRIED/CASADO
GENDER/SEXO
( ) DIVORCED/DIVORCIADO
( ) AFRICAN-AMERICAN/AFRO-AMERICANO
( ) AMERICAN INDIAN/INDIO-AMERICANO
( ) ESPAÑOL
( )F
____________________
( )M
( ) WIDOW/VIUDO
( ) OTHER/OTRO
( ) ASIAN/ASIATICO
( ) OTHER
( ) NOT HISPANIC OR LATINO/NO HISPANO O LATINO
( ) ENGLISH & ESPAÑOL
( ) OTHER
PCP/DOCTOR PRIMARIO
________________________________________________
PHONE/TELEFONO
________________________
EMPLOYER NAME/EMPLEADOR
________________________________________________
PHONE/TELEFONO
________________________
MAILING ADDRESS/ DIRECCION DE CORREO
________________________________________________________________________________
ADDRESS/DIRECCION
PHONE CONTACT/TELEFONOS DE CONTACTO
CITY/CIUDAD
ZIP CODE/CODIGO POSTAL
__________________________________________________________________________
HOME/CASA
EMERGENCY CONTACT/CONTACTO DE EMERGENCIA
RELATIONSHIP/PARENTEZCO
STATE/ESTADO
WORK/TRABAJO
CELL/CELULAR
________________________________________________________________________________
________________________________
PHONE/TELEFONO
__________________________ HOME ¦ WORK ¦ CELL
HEALTH INSURANCE/SEGURO MEDICO
PRIMARY INSURANCE/SEGURO PRIMARIO
POLICY NUMBER/NUMERO POLIZA
________________________________________________________________________________________
___________________________________
GROUP NUMBER/NUMERO GRUPO
________________________
POLICY HOLDER/PROPIETARIO POLIZA
______________________________________
DOB/FECHA NACIMIENTO
________________________
RELATIONSHIP/PARENTEZCO
______________________________________
PHONE/TELEFONO
________________________
OTHER INSURANCES
___________________________________________________________________________________________________________
AUTO INSURANCE/SEGURO DE AUTO
INSURANCE NAME/NOMBRE ASEGURADORA
AGENT NAME/NOMBRE AGENTE
______________________________________________________________________________________
_________________________________________________
DATE OF ACCIDENT/FECHA ACCIDENTE
___________________
POLICY NUMBER/NUMERO DE POLIZA
____________________________________________
ATTORNEY NAME/NOMBRE ABOGADO
____________________________________________
PHONE/TELEFONO
CLAIM NUMBER/NUMERO DE RECLAMO
_________________________
________________________________
PHONE/TELEFONO
_________________________
ENGLISH: I represent and affirm that the above information is true and correct, and it is my understanding that Central Florida Pain & Rehab Clinic is relying on the
above information that I have provided. I have read the “Consent for Treatment, Acknowledgment of Liability and Assignment of Benefits” forms on the following page and
as the patient, or patient’s authorized representative of general agent for the purpose of signing this document. I hereby accept its terms.
ESPAÑOL: Declaro y afirmo que la información anterior es verdadera y correcta, y es mi entendimiento de que Central Florida Pain & Rehab Clinic se basa en la
información anterior que he proporcionado. He leído los formatos anexos " Consent for Treatment, Acknowledgment of Liability and Assignment of Benefits " y que tanto el
paciente como su representante autorizado para firmar este documento aceptan sus términos.
__________________________________
PATIENT SIGNATURE/FIRMA PACIENTE
_________________
DATE/FECHA
NPT-F01, Rev. 1, 08/29/13