Please fill in every box.

 Date(xx-xx-xxxx)

Personal Information

Patient's First Name

Middle Initial

Last Name

Date of Birth

Sex

Social Security Number

Emergency Contact (name and phone of person NOT living in your home and NOT family)

 

Insurance Information Please bring a copy of your insurance card with you upon your first visit to our office

 Name of Primay Insurance

Name of Insured

Address of Insured

Phone Number of Insured

  Phone number

 

If you would like to have medical information (example: test results, medication information) released to someone other than yourself, please complete the following:

Name

Relationship

Name

Relationship

 

 

 

 

I understand that email is not a secure means of transmission for medical documents. This office will not send confidential medical information via email.

I authorize the office of Dr. Hemeyer to leave medical information pertaining to my care to the above people and by the above methods, and I will assume responsibility for notifying this office whenever information changes.

 

 

 

Incomplete forms may not be processed.

Marital Status 

 Address

City State Zip

Home Phone (xxx-xxx-xxxx)

Work Phone

Drivers License Number

 

 

 

 

 

Social Secuirty Number of Insured

How is the patient related to insured

 Insured Date of Birth

Place of Employment

 

 

Please mark the appropriate ways we may contact you or leave messages regarding your medical information.

 

Home Phone:                          yes no

Home Answering Machine:   yes no

Work Phone:                           yes no

Work Voice Mail:                   yes no

Cell Phone:                            yes no

            if yes, number

Pager:                                    yes no

if yes, number

 

I would like a username and password sent to my email so that I may complete forms and requests (example: test results request, billing requests and payments) over a secure connection.

Email Address

 

Dr. Ed Hemeyer • Employees • Contact Us and Directions