Patient Check-In Format
Please take a moment to complete this check-in form with your most up-to-date and accurate information. The details you provide will help us ensure proper care during your visit and keep your medical records current. Your cooperation is essential in helping us deliver the best possible care tailored to your needs.
I. PATIENT INFORMATION
Full Name:
Date of Birth:
Age:
Gender:
Address: ________________________________________
City/State/ZIP: __________________________________
Phone Number: __________________________________
Email: ____________________________________________
II. EMERGENCY CONTACT INFORMATION
Name:
Relationship:
Phone Number:
Alternate Phone:
III. INSURANCE INFORMATION (if applicable)
Primary Insurance Provider: ___________________________
Policy Number: ________________________________________
Group Number: ________________________________________
Insurance Phone Number:
IV. REASON FOR VISIT
Briefly describe the reason for your visit today:
When did your symptoms begin?:
Have you received treatment for this condition before?
If Yes, please explain: _________________________________
V. MEDICAL HISTORY
Do you have any of the following medical conditions?
Are you currently taking any medications?
If Yes, please list: ____________________________________
Any known allergies (e.g., medications, foods, etc.)
If Yes, please list: ____________________________________
VI. CONSENT AND SIGNATURE
By signing below, I confirm that the information provided is accurate to the best of my knowledge.
Signature:
Date:
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