The Weight Loss Center at Pinnaclehealth

The Weight Loss Center at PinnacleHealth

Patient Information Form

Mr. / Mrs. / Ms. - Last Name: ______First Name: ______MI: ______

Previous Last Name: ______

Address Line 1: ______

Address Line 2: ______

City: ______State: ______Zip: ______Country: ______

Home Phone: ______-______-______Cell Phone: ______-______-______Work Phone: ______-______-______Ext: ______

**Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______

Primary Care Physician: ______Referring Provider: ______

Rendering Provider / Primary Care Giver: ______

**Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______

Date of Birth: ______/______/______Sex: Male / Female / Unknown / Transgender

Marital Status: Divorced / Married / Partner / Single / Unknown / Widowed / Legally Separated

Social Security Number: ______-______-______Employer: ______

Employment Status: Full-time / Part-time / Not employed / Self employed / Retired / On active military duty / Reserved for national assignment / Unknown

Student Status: Full-time student / Part-time student / Not a student

**Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______

Emergency Contact:

Relationship:______Last Name: ______First Name: ______MI: ______

Address Line 1: ______

Address Line 2: ______

City: ______State: ______Zip: ______

Home Phone: ______-______-______Work Phone: ______-______-______Ext: ______

Responsible Party (please circle): Self or Emergency Contact

**Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______

Please see page 2 for form completion

Medical Insurance Coverage’s:

Self Pay: Yes _____ No _____

PrimaryInsurance Provider: ______Subscriber Number: ______

Specialist Co-pay: $______Named Insured: ______Self: ______

Group/ID Number: ______Group Name______

If you are not the Primary insurance Subscriber, but an active member on the policy please fill out the information below

Last Name: ______First Name: ______MI: ______

Soc. Sec. Num: ______-______-______DOB: _____/_____/_____ Email: ______Sex: M / F

Address Line 1: ______

Address Line 2: ______

City: ______State: ______Country: ______Zip: ______

Employer: ______Address: ______

City: ______State: _____ Work Phone: ______-______-______Ext: ______Ok To Leave Msg: Yes / No

Secondary Insurance Provider: ______Subscriber Number: ______

Specialist Co-pay: $______Named Insured: ______Self: ______

Group Number: ______Group Name: Please Leave this Line Blank_______

**Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______

Additional Information:

Patient Email Address (please print legibly): ______@______. ______

Email Address not provided: ____ Race: ______Ethnicity: ______

Primary Language: ______Translator Needed: ______

Default Facility: ______

**Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______

Pharmacy:

Pharmacy Name: ______Address Line 1: ______

City: ______State: ____ Zip: ______Phone Number: ______

Please use this line to confirm no changes to the information previously listed for year: ______Patient Initials: ______