Youth Care/Same Day Care

PATIENT DATA

Please complete the ENTIRE form Today's Date:                                         
Patient's Name:                                                                                                                                     
                           First                                         Middle                                                 Last
Birth Date:                       SS#                      

GENDER:    Male     Female  (circle one)

Drug Allergies:                                                                                                                                      

Parent / Legal Guardians / Self / Spouse (Circle One) 

MOTHER'S INFORMATION: FATHER'S INFORMATION:
Name:                                                                 Name:                                                                
            First         Middle      Maiden         Last               First            Middle               Last
Home Phone:                                                       Home Phone:                                                     
Cell Phone:                                                          Cell Phone:                                                        
Address:                                                              Address:                                                            
City:                        State:               Zip:               City:                        State:               Zip:              
SS#                              Date of Birth:                   SS#                              Date of Birth:                 
Occupation:                                                         Occupation:                                                       
Place of Employment:                                          Place of Employment:                                         
Address:                                                              Address:                                                             
City:                        State:               Zip:               City:                        State:               Zip:              
Phone:                                                                 Phone:                                                                

 Marital Status: (Circle One)

Marital Status: (Circle One)

Unmarried       Married 

Unmarried       Married 

 Divorced       Separated       Widowed

Divorced       Separated       Widowed

BROTHERS/SISTERS:

Full Name

Birth Date

Seen in this Office ?

Yes          No

1.                                                           

     -      -   

                              

2.                                                            

     -      -   

                             

3.                                                           

     -      -   

                             

 Youth Care/ Same Day Care

Insurance Data

Please complete the ENTIRE form Today's Date:                                         
IN CASE OF EMERGENCY:
Please Contact:                                                          Phone #:                                        
Responsible Party (if other than patient)                                                                                   
Relation to Patient:                                     
Address:                                                                                                                                 
                       Street                                      City                              State                  Zip
 PLEASE READ: It is understood that all charges are due at the-time of service unless other arrangements have been made in advance with our office. It is understood that the patient (or responsible party) is responsible for payment regardless of insurance coverage (contract plans excepted). A $25.00 service fee will be charged in the event of a returned check.

NOTE: Responsible party is the legal guardian of any minor (under 18 years of age) bringing him/herself in for treatment or the parent bringing the child in.

Signed:                                                                                     Date:                         

Primary Insurance:

Secondary Insurance:

Co. Name:                                                         Co. Name:                                                        
Address:                                                             Address:                                                           
                                                                                                                                                   
City                     State                  Zip City                     State                  Zip
Name of Policy Holder                                        Name of Policy Holder                                      
Certificate #                                                        Certificate #                                                       
Group #                                                              Group #                                                             
SS #                                                                   SS #                                                                  

Date of Birth:                                        Employer:                                                                               

"I request that payment under the medical insurance program be made either to me or on my behalf to Youth Care/ Same Day Care for any services furnished me by that provider and I authorize any holder of medical information about me to release to my insurance company, or its agents, any information needed to determine these benefits."

  Signed:                                                                                     Date: