LACEY MEDICAL CLINIC
PATIENT DEMOGRAPHIC INFORMATION
Patient’s Name:___________________________________________________________
Last
First
Date of Birth :_______/_______/_______
Initial
Gender: Male or Female (please circle)
Social Security #: (optional) _________________________________________________
Marital Status: Single / Married / Separated / Divorced / Widowed / Child (please circle one)
Address:_________________________________________________________________
Street
Apt. #
______________________________________________________________________________
City
State
Zip
Employer:___________________________
Occupation:_________________________
Contact Numbers: _________________________________________________________
Home
Cell
Work
Preferred Pharmacy: ______________________________________________________
Name
Address
City
Email: _________________________________________________________________
Contact Preference: Home / Cell / Work / E-mail / Mail (please circle one)
Preferred Provider: _______Ronald Krauss, MD
_______Will Leighty, MD
_______ Evelyn “Rosalie” Sabroe, ARNP
_______ Ruth Schaffler, ARNP
Race: Please select one:
Ethnicity:
____ American Indian and Alaskan Native
____ Hispanic or Latino
____ Asian
____ Not Hispanic or Latino
____ Black or African American
____ Black Hispanic or Latino
____ Native Hawaiian and other Pacific Islander
____ White
____ White Hispanic or Latino
Preferred Language: ________________________________________________________
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Responsible Party Name (spouse or parent): ______________________________________
Responsible Party’s Address: (if different than patients)_______________________________________
PRIMARY INSURANCE PLAN: ____________________________________________
Primary Insurance ID #: _____________________ Group Number: ___________________
Copay: _________________ Insurance Address: _________________________________
Insurance Plan Phone #: ________________ Guarantor’s Employer: ___________________
Guarantor’s Name: ________________________ Guarantor’s DOB: ____/____/_____
Patient relationship to guarantor: Self / Spouse / Child / Other
SECONDARY INSURANCE: ________________________________________________
Secondary Insurance ID #: _____________________ Group Number: __________________
Copay: _________________ Insurance Address: __________________________________
Insurance Plan Phone #: ________________ Guarantor’s Employer: ___________________
Guarantor’s Name: ________________________ Guarantor’s DOB: ____/____/_____
Patient relationship to guarantor: Self / Spouse / Child / Other
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PERSON(S) TO NOTIFY IN CASE OF EMERGENCY
_________________________________________________________________________
Name
Address
City
State
Zip
_______________________________________________________________________________________
Contact Numbers: Home
Cell
Work
Relationship to Patient
_________________________________________________________________________
Name
Address
City
State
Zip
_______________________________________________________________________________________
Contact Numbers: Home
Cell
Work
Relationship to Patient
I was referred to this office by_______________________________________________
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I hereby release insurance payments to be made directly to Lacey Medical Clinic. I am
financially responsible for any balance due after insurance. I authorize the doctor or
insurance company to release any PHI (Protected Health Information) for treatment,
payment or healthcare operations without prior authorization.
________________________________________________________________________
SIGNATURE OF PATIENT (Parent or Guardian if patient is a minor)
Today’s Date