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UROLOGY SPECIALISTS, S.C.
CONFIDENTIAL INFORMATION
PLEASE PRINT & COMPLETE IN FULL
Today's date/date of appointment: ____________________
Please indicate the doctor you are seeing today: |
Account # _______________ |
| _____ Jerome Hoeksema, M.D. _____ Laurence A. Levine, M.D. |
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PATIENT INFORMATION
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| SOCIAL SECURITY: ______/______/______ |
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| LAST NAME: _________________________ |
FIRST NAME: _________________________ |
| ADDRESS: ____________________________________________________________________ |
| CITY: ______________________________ |
STATE: ___________ ZIP: _____________ |
| HOME PHONE: (_______)________-________ |
WORK PHONE: (_______)________-________ |
| DATE OF BIRTH: ______/______/______ |
AGE: ________ SEX: (CIRCLE) F or M |
| MARITAL STATUS: ___SINGLE ___MARRIED ___WIDOWED ___DIVORCED ___SEPARATED |
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RESPONSIBLE PARTY IF OTHER THAN PATIENT
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| SOCIAL SECURITY: ______/______/______ |
| RESPONSIBLE PARTY NAME: _____________________________________________________ |
| ADDRESS: ____________________________________________________________________ |
| CITY: ______________________________ |
STATE: ___________ ZIP: _____________ |
| HOME PHONE: (_______)________-________ |
WORK PHONE: (_______)________-________ |
| DATE OF BIRTH: ______/______/______ |
SEX: (CIRCLE) F or M RELATION: _________ |
| RESPONSIBLE PARTY EMPLOYER: __________________________________________________ |
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PATIENT EMPLOYER INFORMATION
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| EMPLOYER: ___________________________________________________________________ |
| ADDRESS: ____________________________________________________________________ |
| CITY: ______________________________ |
STATE: ___________ ZIP: _____________ |
| WORK PHONE: (______)_______-_______ |
OCCUPATION: _________________________ |
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EMERGENCY CONTACT
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| RELATIVE/FRIEND: _____________________________________________________________ |
| HOME PHONE: (_______)________-________ |
WORK PHONE: (______)________-________ |
| RELATIONSHIP: ________________________________________________________________ |
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EMERGENCY CONTACT THAT DOES NOT LIVE IN HOUSEHOLD
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| NAME: _______________________________________________________________________ |
| HOME PHONE: (_______)________-________ |
WORK PHONE: (______)________-________ |
| RELATIONSHIP: ________________________________________________________________ |
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INSURANCE INFORMATION (WE REQUIRE A COPY OF YOUR CARD)
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| PRIMARY INSURANCE: __________________________ |
COPAY: Y or N AMOUNT:$_______ |
| POLICYHOLDER: _______________________________ |
RELATIONSHIP: __________________ |
| DATE OF BIRTH: ______/______/______ |
PERCENTAGE PLAN PAYS: __________ |
| INSURANCE ADDRESS: ____________________________________________________________ |
| CITY: ______________________________ |
STATE: _______ ZIP: ___________ |
| HOME PHONE: (_______)________-________ |
EFF. DATE OF POLICY:____________ |
| IF THROUGH AN EMPLOYER, GIVE EMPLOYER NAME: ___________________________________ |
| POLICY NUMBER: _______________________ |
GROUP NUMBER: _________________ |
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| SECONDARY INSURANCE: _______________________ |
COPAY: Y or N AMOUNT:$_______ |
| POLICYHOLDER: _______________________________ |
RELATIONSHIP: __________________ |
| DATE OF BIRTH: ______/______/______ |
PERCENTAGE PLAN PAYS: __________ |
| INSURANCE ADDRESS: ____________________________________________________________ |
| CITY: ______________________________ |
STATE: _______ ZIP: ___________ |
| HOME PHONE: (_______)________-________ |
EFF. DATE OF POLICY:____________ |
| IF THROUGH AN EMPLOYER, GIVE EMPLOYER NAME: ___________________________________ |
| POLICY NUMBER: _______________________ |
GROUP NUMBER: _________________ |
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| TERTIARY INSURANCE: __________________________ |
COPAY: Y or N AMOUNT:$_______ |
| POLICYHOLDER: _______________________________ |
RELATIONSHIP: __________________ |
| DATE OF BIRTH: ______/______/______ |
PERCENTAGE PLAN PAYS: __________ |
| INSURANCE ADDRESS: ____________________________________________________________ |
| CITY: ______________________________ |
STATE: _______ ZIP: ___________ |
| HOME PHONE: (_______)________-________ |
EFF. DATE OF POLICY:____________ |
| IF THROUGH AN EMPLOYER, GIVE EMPLOYER NAME: ___________________________________ |
| POLICY NUMBER: _______________________ |
GROUP NUMBER: _________________ |
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REFERRED BY
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| REFERRING PHYSICIAN: __________________________________________________________ |
| ADDRESS: ____________________________________________________________________ |
| CITY: ______________________________ |
STATE: ___________ ZIP: _____________ |
| OFFICE PHONE: (______)_______-_______ |
OFFICE FAX: (______)_______-_______ |
| If not referred by a physician, how did you hear about our office (check one): |
| ___WEBPAGE ___YELLOW PAGES ___FRIEND/FAMILY ___RADIO ___INSURANCE DIRECTORY |
| ___TV ___EMERGENCY ROOM VISIT ___NEWSPAPER ___OTHER: ______________________ |
| PRIMARY CARE PHYSICIAN NAME (if different from above): ______________________ |
| ADDRESS: ____________________________________________________________________ |
| CITY: ______________________________ |
STATE: ___________ ZIP: _____________ |
| OFFICE PHONE: (______)_______-_______ |
OFFICE FAX: (______)_______-_______ |
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