Emmanuel Family Practice Associates

Available Forms

Patient Demographic Form Patient History

Patient Demographic Form

IF YOU HAVE COMPLETED A NEW DEMOGRAPHIC FORM IN THE OFFICE WITHIN THE LAST YEAR, YOU DO NOT NEED TO COMPLETE THIS FORM UNLESS THERE ARE CHANGES TO REPORT.

PATIENT INFORMATION

Salutation

Last Name *

First Name *

Middle Name

Suffix

Date of Birth *

Gender *

Male

Female

Social Security Number *

Marital Status

Single

Married

Divorced

Widowed

Partnered

Other

Address (Line 1) *

Address (Line 2)

City *

State *

Zip Code *

Home Phone *

If you do not have a land line phone, please enter cell phone number, or other number that you can be reached at.

Cell Phone

Work Phone

Email Address

Required if you wish to have access to the patient portal.

Race *

Ethnicity *

Language *

Allergies

Employer/Occupation

Organ Donor

Yes

Living Will

Yes

RESPONSIBLE PARTY (GUARANTOR) INFORMATION

Relationship to Patient *

Self (If self, skip to Emergency/Next of Kin section)

Parent

Spouse

Other

Please provide

Guarantor Last Name

Guarantor First Name

Guarantor Middle Name

Guarantor Date of Birth

Guarantor Social Security Number

Guarantor Gender

Male

Female

Guarantor Address (Line 1)

Guarantor Address (Line 2)

Guarantor City

Guarantor State

Guarantor Zip Code

Guarantor Home Phone

Guarantor Work Phone

Guarantor Cell Phone

EMERGENCY CONTACTS/NEXT OF KIN

Primary Contact

Last Name *

First Name *

Relationship to Patient *

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Home/Primary Phone *

If you do not have a land line phone, please enter cell phone number, or other number that you can be reached at.

Cell Phone

Work Phone

Secondary Contact

Last Name

First Name

Relationship to Patient

Address (Line 1)

Address (Line 2)

City

State

Zip Code

Home/Primary Phone

If you do not have a land line phone, please enter cell phone number, or other number that you can be reached at.

Cell Phone

Work Phone

PREFERRED PHARMACY INFORMATION

Name of the pharmacy you most frequently use *

If you aren't on any medications, enter "N/A" for the below fields.

Pharmacy Address *

Pharmacy City *

Pharmacy State *

Pharmacy Zip Code *

Pharmacy Phone Number *

Do you use a Mail Order Pharmacy? *

Yes

If yes, please select Mail Order Pharmacy

Medco/Express Scripts

CVS Caremark

Other

Does your prescription plan REQUIRE you to use Mail Order? *

Yes

Unknown

Primary Insurance Plan

Do you have insurance? *

Yes

Primary Insurance Plan Name

Primary Insurance Address Line 1

Primary Insurance Address Line 2

Primary Insurance City

Primary Insurance State

Primary Insurance Zip Code

Primary Insurance Telephone No.

Primary Insurance ID No.

Primary Insurance Group No.

Secondary Insurance Plan

Secondary Insurance Plan Name

Secondary Insurance Address Line 1

Secondary Insurance Address Line 2

Secondary Insurance City

Secondary Insurance State

Secondary Insurance Zip Code

Secondary Insurance Telephone No.

Secondary Insurance ID No.

Secondary Insurance Group No.

* Required field