Demographics – Primary Care Clinic for Adults

Patient Name *

First

Last

Date of Birth *

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Preferred Language *

Race *

Marital Status *

Ethnicity *

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Physical Address *

Address Line 1

City

State

Zip Code

Mailing Address (if different from physical)

Address Line 1

City

State

Zip Code

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Preferred Phone Number *

May we leave a detailed message? *

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Preferred Email *

May we discuss your health via email? *

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Emergency Contact Name & Relationship *

Emergency Contact Phone &/or Email *

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Insurance Name *

Insurance ID & Group Number *

Guarantor Name, Address, Phone, Email (if other than self)

(Financially Responsible Party)

By completing this form clicking Submit below, I: (please agree to each)

Authorize APCCFA to release medical information to my insurance company in order to facilitate the processing of medical claims on my behalf.
Understand that any tests performed outside of this office will be billed separately by another entity and these charges are my responsibility. This includes labs, imaging or services rendered by another office. This is in addition to any charges from APCCFA.
Authorize treatment of the above named patient and agree to pay all fees for treatment.
Authorize my insurance benefits be paid directly to APCCFA.
Understand that there will be a $50 fee assessed for any returned check. The fee and the amount of the origianl check must be paid in full prior to any further visits.

Name *

First

Last

Date / Time *

Date

Time