Simon Family Medicine

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Available Forms

New Patient Information Patient Health History (For New Patients Only)

New Patient Information

Patient Information

Today's Date

First Name *

Middle Name

Last Name *

Birthdate *

mm/dd/yyyy

Gender *

Male

Female

SSN *

Marital Status

Single

Married

Other

Patient Address

Mailing Address

City

State

Zip Code

Preferred Pharmacy *

If your pharmacy is NOT listed, please provide the information below.

Pharmacy Name

Pharmacy Phone

Street Address

City, State

e-mail address

Providing us with your e-mail will facilitate appointment reminders and provide you with free patient portal to access your lab results upon your request. We will not distribute or sell your e-mail address to any third party.

Home Telephone *

Cell Phone

Work Phone

Contact Preference

Home Phone

Cell Phone

Work Phone

e-mail

Employer/School Name

Previous physician/practice name

How did you hear about us?

If other, please list below.

Other:

Census Bureau Categorization

Barriers to Communication

None

Vision

Hearing

Language Preference

Race

Ethnicity

Emergency Contact

Full Name (First, Last) *

Phone Number *

Gender *

Male

Female

Relationship to Patient *

If Other, please signify below:

Primary Insurance Information

Do you have insurance? *

Yes

No*

*Payment/Co-Payment must be paid at the time of service. We accept Cash, Checks, Visa and MasterCard. <br/><br/>If you do not have insurance, please select 'Self Pay' for Name of Insurance.

Name of Insurance *

If other, please indicate below the name of your insurance.

Other

Primary Insurance ID Number *

Group Number

Co-Pay Amount

Issued Date

Primary Insurance Phone

Subscriber

Patient is the Subscriber

Patient is NOT the Subscriber

Please complete the info below if the Patient is NOT the subscriber to the primary insurance.

Subscriber Full Name (Last, First, MI)

Subscriber Birthdate (mm/dd/yyyy)

Patient Relationship to Subscriber

Self

Spouse

Child

Other

Secondary Insurance

Insurance Plan (Secondary)

Insurance ID No. (Secondary)

Group Number

Copay

Subscriber

Patient is the subscriber

Patient is NOT the subscriber

Please complete the info below if the Patient is NOT the subscriber to the secondary insurance.

Subscriber Full Name (Last, First, MI)

Subscriber Birthdate (mm/dd/yyyy)

Secondary Insurance Phone

Guarantor's Name (L, F, MI)

Guarantor

Guarantor *

Patient is the Guarantor

Patient is NOT the Guarantor

If Patient is NOT the Guarantor, please provide the answers below:

Guarantor's Full Name (First, MI, Last)

Mailing Address *

Same as Patient's Address

If not, please provide Guarantor's address below.

Mailing Street Address

City

State

Zip Code

Guarantor's Birthdate

(mm/dd/yyyy)

Guarantor's Relationship to Patient

Spouse

Child

Parent

Other

Guarantor's Gender

Male

Female

Primary Guardian?

Yes

Thank you for completing our secure online New Patient Information form. Please remember to bring a picture ID and if you have insurance, your insurance card with you to your appointment. If you cannot make it to your appointment, please give us at least 24 hours notice or a $50 no-show fee will be charged. If you are unable to recall your current medication information, please bring your medications or a list of your medications with dosage and how you take them to each visit. If you have any questions, please call 777-8008 and press 1 to speak to the receptionist.

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