New Patient Form - Farmer Family Practice

"*" indicates required fields

Step 1 of 4

Comments

This field is for validation purposes and should be left unchanged.

Patient Registration

Name*

First Middle Last

Social Security Number*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone*

Can we text you?*

Yes

Secondary Phone

Email*

please input NA if not applicable

Please choose one*

Male

Female

As part of the American Recover & Reinvestment Ace, healthcare providers are required to obtain the following information. Please select which most applies to you*

Employer

Please input NA if this is not applicable.

Occupation

Please input NA if this is not applicable.

Employer Phone

Please input NA if this is not applicable.

Spouse/Partner

Please input NA if this is not applicable.

Phone

Emergency Contact*

Phone*

Relationship*

Previous Primary Care Physician*

Please input NA if this is not applicable.

Previous PCP Address

Street Address Address Line 2 City State ZIP Code

Previous PCP Phone

Pharmacy*

Please input NA if this is not applicable.

Pharmacy Address

Street Address Address Line 2 City State ZIP Code

Pharmacy Phone

How did you hear about us?

Is the patient a minor?*

Yes

Responsible Party

Responsible party name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Employer Name

Please input NA if this is not applicable.

Employer Phone

Social Security Number*

Date of Birth*

Parent Name*

First Last

Who does the child live with?*

Do you have an Insurance provider?*

Yes

Insurance Information

Insurance Company*

Please input NA if this is not applicable.

Effective Date*

Claims Address

Street Address Address Line 2 City State ZIP Code

Policy / ID #*

Please input NA if this is not applicable.

Group #*

Please input NA if this is not applicable.

Policy Holder*

Please input NA if this is not applicable.

Date of Birth

Relationship*

Employer

Phone

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have a secondary Insurance company?*

Yes

Secondary Insurance Information

Insurance Company*

Effective Date*

Claims Address

Street Address Address Line 2 City State ZIP Code

Policy / ID #*

It is required to put your Policy ID #

Group #*

Please input NA if this is not applicable.

Policy Holder*

Date of Birth

Relationship*

Employer

Phone

Address

Street Address Address Line 2 City State ZIP Code

FINANCIAL POLICY

Payment is due at the time services are rendered, this includes self-pay, insurance co-payments and/or deductibles. A current insurance card must be on file. As a service to our patients, we will file your medical claims for date-of-service with insurance information we have available at that time. It is your responsibility to inform us of any changes in your insurance or personal information, such as address and/or phone changes. I hereby authorize and assign payment of medical benefits directly to Farmer Family Practice. I authorize medical information needed to determine these benefits or the benefits payable for the related services be released to the insurance company and its agents. I understand that even though I have some type of insurance coverage, I am responsible for the payment and it is due upon request. I further understand that should my account become delinquent, I shall pay the reasonable attorney fees or collection expense of Farmer Family Practice, if any, including but not limited to, a collection fee of up to 25% of the debt. I have been given Farmer Family Practice’s Patient Financial Policies and Rights and Responsibilities. The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing below that I am responsible for payment of services in full before services are rendered.

Patient Name*

Signature

Date*

CONSENT TO TREAT

Patient Name*

Signature*

Date*

COMPLETE IF PATIENT IS A MINOR

List of names for consent*

First Name

Last Name

Signature of Parent or Legal Guardian*

Date*

ACKNOWLEDGEMENT OF RECEIPT OF FARMER FAMILY PRACTICE NOTICE OF PRIVACY PRACTICES

Patient Name*

Signature of patient, parent, or legal guardian*

Date*

RELEASE OF MEDICAL RECORDS

List

Name

Relationship to Patient

Farmer Family Practice

Patient Registration

Responsible Party

Insurance Information

Secondary Insurance Information

Additional Information

Mammogram

Pap Test

Bone Density

Colonoscopy

EGD

Eye Exam

Dental

Additional Information

Smoking Information

Drinking Information

Caffeine Information

Exercise Information

Section Break

Illegal Drugs Information

Medical History

ADHD/ADD

Alcoholism

Alzheimer's/Dementia

Arthritis

Asthma

Blood Clots

Bleeding Disorder

Bowel Disease

Breathing Disorder

Cancer

Depression / Anxiety

Diabetes

Eye Disease

Heart Attack

High Blood Pressure

High Cholesterol

Kidney Disease

Mental Illness

Migraines

Osteoporosis

Seizure Disorder

Stroke

Thyroid Disease

Other

Vaccination History

Flu

Pneumonia

Shingles

COVID

Tetanus