Patient Information - Please Print

Patient Information - Please Print

Today’s Date:_________________ Email Address:_____________________________________________________

Patient’s Name:_____________________________________________________________________________________

(LAST) (FIRST) (MIDDLE INTIAL)

Local Address:______________________________________________________________________________________

City:___________________________________ State:______________ Zip Code:__________________

Billing Address:______________________________________________________________________________________

City:___________________________________ State:______________ Zip Code:__________________

Home Phone: ( )____________________ Pref Y / N Cell Phone: ( )_______________________Pref Y / N

Age:____ Date of Birth: ____/ ____/ ____ Sex □ M □ F Social Security #:_______________________________

Marital Status: □ Single □ Married □ Divorced □ Separated □ Widowed □ Minor

Ethnicity: □ Hispanic or Latino □ Not Hispanic or Latino □ Unknown □ Declined to Specify

Race: □ American Indian/Alaskan Native □ Asian □ Black or African American

□ Native Hawaiian or Other Pacific Islander □ White □ Other Race □ Declined to Specify

If Minor, Responsible Parties:__________________________________________________________________________

If different address than above:________________________________________________________________________

City:___________________________________ State:______________ Zip Code:__________________

Primary Insurance Carrier:_____________________________________ Policy #:_________________________

Secondary Insurance Carrier:___________________________________ Policy #:_________________________

Insurance Policy Holder:_______________________________________ Date of Birth:_____/ _____/ _____

Employer:______________________________________ Occupation:_____________________________

How did you hear of SMC? □ Internet □ Family/Friend □ Insurance □ Other ______________________________

If Auto Accident Case:

Auto Insurance Carrier:_____________________________________ Phone:_________________________________

Claim #: ______________________________________ Policy #: ______________________________________

Adjuster’s Name: _______________________________ Date of Accident: _______________________________

Attorney: _____________________________________ Attorney Phone: ________________________________

Contact/ Case Manager: _________________________

If Worker’s Compensation Case:

Employer: ____________________________________________ Date of Injury: ___________________________

Work Comp Insurance Company: _______________________________ Case Manager: __________________________

Claims Mailing Address: ______________________________________________________________________________

Claim #: _____________________________________ Phone #: _______________________________