Privacy Notice Signature Form

Legal Name: Last, First, Middle
Home Phone/Work Phone/Cell Phone/E-mail Address/Address
Date of Birth
Marital Status
Gender
Employer/ Occupation

Emergency Contact  (outside of your home)

Name/Contact Phone/Relationship

SPOUSE/GUARDIAN

Legal Name/Home Phone/Work Phone/Cell Phone/Address
Date of Birth

INSURANCE INFORMATION

How do you intend to pay for your visit? Cash/Check/Credit Card/Insurance

Primary Health Insurance:
Insurance Company/Mailing/Address/
Policy or ID Number/Group Number/Insured Name
Relationship to insured: Self/Spouse/Child

Secondary Health Insurance:

Insurance Company/Mailing/Address
Policy or ID Number/Group Number/Insured Name
Relationship to insured: Self/Spouse/Child

PREFERRED PHARMACY INFORMATION

Mail order Pharmacy/Local Pharmacy name & phone number