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NEW PATIENT INFORMATION SHEET
It is very important that you complete the entire form, sign and date.
DATE: ____________________
PATIENT INFORMATION:
Last Name:___________________________________________First: ____________________________________MI:_________________
Street Address: __________________________________________Mailing Address:____________________________________________
City: _____________________________________________________ State: ________________ Zip Code:________________________
Social Security Number: _________ / __________ / __________ Date of Birth:__________ / __________ / __________
Home Phone: ( ______ ) ________________________________________Work Phone: ( ______ ) ________________________________
Employer: ___________________________________________________________ Occupation: __________________________________
Employer’s Address: _______________________________________________________________________________________________
Marital Status: ____________________ Spouse’s Name: ___________________________________________________________________
Spouse’s Social Security # ________ / ________ / ________ Spouse’s Date of Birth: ________ / ________ / ________
Spouse’s Employer:___________________________________ Spouse’s Employer Phone: ( ______ ) ______________________________
Spouse’s Employer’s Address: ________________________________________________________________________________________
Emergency Contact Person: ______________________________________________ Relationship: ________________________________
Phone Number: ( ______ ) _________________________________________Address: _________________________________________
May we call and leave you a message on your answering machine: _______Yes ______No With your spouse: ______Yes ______No
Are you currently a student? _____ Full Time _____ Part Time
Name and Address of School:_________________________________________________________________________________________
Parent’s Name: ____________________________________________________________________________________________________
Parent’s Address: __________________________________________________________________________________________________
How did you hear about CMC? __ Physician Referral __ News Paper __ Radio __Billboard
__ Friend Referral __ Insurance Plan __ Other ____________________________________
Primary Insurance Carrier: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
Subscriber’s Name: ___________________________________________ Effective Date: _________________________________________
Policy or ID #: ______________________________________________ Group #: ______________________________________________
Primary Care Physician: ______________________________________ Effective Date: _________________________________________
Referring Doctor: __________________________________________________________________________________________________
Secondary Insurance Carrier:_________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
Subscriber’s Name: ___________________________________________ Effective Date: _________________________________________
Policy or ID #: ______________________________________________ Group #: ______________________________________________
Primary Care Physician: ______________________________________ Effective Date: __________________________________________
Referring Doctor: __________________________________________________________________________________________________
I hereby authorize direct payment of surgical/medical benefits to Cookeville Medical Center, P.C. for the services rendered to
_____________________________. I understand that I am financially responsible for any balance not covered by my insurance, as
allowed by law or by my insurance plan. I understand that if I have no insurance coverage, payment is due in full at time of service.
Further, I agree that if it is necessary to refer this account to an agency, attorney or court for collection, I will pay all costs related
to such collection action. I authorize Cookeville Medical Center, P.C., and its physicians to release any medical or incidental
information and to request medical records from any health source that may be necessary for either medical care, or in processing
medical claims. I understand that employees of Cookeville Medical Center access my medical chart for treatment, payment and
operations of the clinic.
_________________________________________________________________ ________________________________________
(Patient/Parent/Guardian Signature) (Date)
INSURANCE INFORMATION: