PATIENT INFORMATION SHEET

Guarantor / Primary Policy Holder Other Parent / Secondary Guarantor

Name __________________________________ Name ___________________________________

Address_________________________________
City _________________St ______Zip _______
Phone _______________Cell _______________
Birth date ____________Wk phone __________
SS#_________________
Address__________________________________
City __________________St ______Zip _______
Phone ________________Cell _______________
Birth date _____________Wk phone __________
SS#_________________

PRIMARY INSURANCE INFORMATION SECONDARY INSURANCE INFORMATION

Insured's Name ___________________________ Insured's Name ___________________________

Insured's Birth date________________________
Employer________________________________
Insurance Co._____________________________
Policy # _________________________________
Group # _________________________________
Effective Date_____________________________
Insured's Birth date________________________
Relationship to Primary Insured ______________
Employer________________________________
Insurance Co._____________________________
Policy # _________________________________
Group # _________________________________
Effective Date_____________________________

ALL CHILDREN

Name Birth date Male/Female Special Insurance #

1._______________________________________________________________________________________
2._______________________________________________________________________________________
3._______________________________________________________________________________________
4._______________________________________________________________________________________
5._______________________________________________________________________________________
6._______________________________________________________________________________________
7._______________________________________________________________________________________
8._______________________________________________________________________________________

Who may we contact if the immediate family is not available?_______________________________________

Phone #_________________________________________

ASSIGNMENT OF BENEFITS: I hereby assign all medical and/or surgical benefits, to include major medical
benefits to which I am entitled, private insurance and other health plans to: Douglas R. Coombs, MD. This
assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be as valid as
the original. I understand that I am financially responsible for all charges whether or not paid by said insurance,
including responsible attorney fees at 18% per annum. I hereby authorize said assignee to release all information
necessary to obtain payment.

Signature_________________________________________________Date_____________________________