New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Bowers, MARK	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Health Care Options AARP HEALTH CARE OPTIONS ACORDIA NATIONAL Advantra Freedom ADVANTRA FREEDON/PUBLIC EMPLOY AETNA Alliance for Business Training ALLIANCE PPO Allied ALTERNATIVE BENEFIT PLANS. American Continenetal Insurance Company AMERICAN HEALTH GROUP AMERICAN HEALTHCARE ALL / PHP AMERICAN HERITAGE LIFE INS CO AMERICAN PIONEER Amerigroup Railroad Retirement Board AMERIHEALTH ADMINSTRATORS Ameritas AMMARS INC ABA CLAIMS DEPT ANTHEM BLUE CROSS APWU Health Plan ASSOCIATED ADMINSTRATOR ASSURANT HEALTH TIME INS CO AVMA Group Health AVMA GROUP HEALTH & LIFE INS BAKERY AND CONFECTIONARY UNION BANKERS LIFE AND CASUALTY CO.Q Beechnut Street Benefit Management Services BLUE CARE Brotherhood Mutual Caremark CARITEN PREFERRED Cariten Senior Health CDS GROUP HEALTH CENTRAL STATES CHAMPVA CIGNA HEALTH CARE CLARITY VISION CLARITY VISION CM ADIMINISTRATORS COLE VISION Commerce Benefits Group Conseco Insurance Company CONTINENTAL LIFE INS CORPORATE SYSTEMS ADMIN. Coventry Health Care CrestPoint Health DAVIS VISION DEFINITY HEALTH DeltaUSA DMERC CARRIER Emeritus EMPLOYEE PLANS , LLC EYE MED Federated Mutual Fidelity Security Life Insurance FISERV HEALTH Flightcare FORTIS INSURANCE COMPANY GE FINANCIAL EMPLOYER SERVICES GEHA GM-SOUTHWEST Golden Rule Insurance Company GREAT-WEST LIFE &ANNUITY INS. Great American Life Guarantee Trust Life Guardian Group Medical Claims Hammerman and Gainer Harrington Health Harrington Helth HEALTH NET COMMERCIAL CLAIMS Health Plan Services HEALTHASPEX C/O MCA ADMIN HealthMarkets Care Assured Healthscope HIGHLANDS WELLMONT HEALTH HOME TOWN AMS/CHANDLER GROUP HUMANA CLAIMS Humana Vision Care Plan Integra BMS KANAWHA HEALTHCARE SOLUTIONS KANAWHA HEALTHCARE SOLUTIONS LIFEWISE HEALTH PLAN OF OREGON March Vision MAS Benefits MAS Benefits MCA Administrators MEDCO HEALTH SOLUTIONS MEDICAID GOVT BENEFIT MEDICARECOMPLETE UNITEDHEALTHC Mediplus MERITIAN HEALTH MOUNTAIN STATES HEALTH ALLIANC MUTUAL OF OMAHA MVP health care National Union Fire Insurance Nippon Life Benefits NORTH AMERICAN NORTH AMERICAN ADM NovaNet OPTICARE PALMETTO PHP TENN CARE Plan Administrators Inc POMCO GROUP Preferred Care Preferred One Community Healthcare PREFRERRED HEALTH PARTNERSHIP Primary Care Physicians Prime Health Services PRINCIPAL LIFE INS PRIVATE HEALTHCARE SYSTEMS PROFESSIONAL CLAIMS MANGT INC PYRAMID CLAIMS QMB RAILROAD MEDICARE Retiree Medical Insurance RSL Speciality Products Admin S&S HEALTHCARE STRATEGIES SE Pipetrades Secure Horizons Medicare Complete SECUREHORIZONS DIRECT SELF INSURED SERVICES COMPANY SISCO SITE ASSISTANCE INTERNATIONAL SOUTHERN HEALTH SERVICES SPECTERA STANDARD LIFE State Farm State of Tennesse Medicaid SULLIVAN COUNTY JAIL SummaCare Sun Life Financial SUPERIOR VISION PLAN TENNCARE JOHN DEERE THE J.P. FARLEY CORPATION THE MAIL HANDLERS BENEFIT PLAN THE MEGA LIFE &HEALTH INS CO THE PYRAMID LIFE INS CO TLC laser clinic TN ANTHEM TN BLUE TN MEDICARE Todays Options Pyramid TradeBank TRICARE SOUTH REGION CLAIMS RE UFCW UNIONS UHC rivervalley-Americhoice UMR UMWA CAREMARK UNICARE USA MCO UNITED AMERICAN INSURANCE United Commercial Travelers of America United Healthcare River Valley United Healthcare River Valley 95378 UNITEDHEALTHCARE USA-MCO VALUE PLAN VISION SERVICE VETERANS ADMINISTRATION Virginia Medicare VISION BENEFIT OF AMERICA VISION CARE PLAN VISION SERVICE PLAN VISION USA Washington County Benefits WAUSAU BENIFETS WEBTPA WellCare Wells Fargo Windsor
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP Health Care Options AARP HEALTH CARE OPTIONS ACORDIA NATIONAL Advantra Freedom ADVANTRA FREEDON/PUBLIC EMPLOY AETNA Alliance for Business Training ALLIANCE PPO Allied ALTERNATIVE BENEFIT PLANS. American Continenetal Insurance Company AMERICAN HEALTH GROUP AMERICAN HEALTHCARE ALL / PHP AMERICAN HERITAGE LIFE INS CO AMERICAN PIONEER Amerigroup Railroad Retirement Board AMERIHEALTH ADMINSTRATORS Ameritas AMMARS INC ABA CLAIMS DEPT ANTHEM BLUE CROSS APWU Health Plan ASSOCIATED ADMINSTRATOR ASSURANT HEALTH TIME INS CO AVMA Group Health AVMA GROUP HEALTH & LIFE INS BAKERY AND CONFECTIONARY UNION BANKERS LIFE AND CASUALTY CO.Q Beechnut Street Benefit Management Services BLUE CARE Brotherhood Mutual Caremark CARITEN PREFERRED Cariten Senior Health CDS GROUP HEALTH CENTRAL STATES CHAMPVA CIGNA HEALTH CARE CLARITY VISION CLARITY VISION CM ADIMINISTRATORS COLE VISION Commerce Benefits Group Conseco Insurance Company CONTINENTAL LIFE INS CORPORATE SYSTEMS ADMIN. Coventry Health Care CrestPoint Health DAVIS VISION DEFINITY HEALTH DeltaUSA DMERC CARRIER Emeritus EMPLOYEE PLANS , LLC EYE MED Federated Mutual Fidelity Security Life Insurance FISERV HEALTH Flightcare FORTIS INSURANCE COMPANY GE FINANCIAL EMPLOYER SERVICES GEHA GM-SOUTHWEST Golden Rule Insurance Company GREAT-WEST LIFE &ANNUITY INS. Great American Life Guarantee Trust Life Guardian Group Medical Claims Hammerman and Gainer Harrington Health Harrington Helth HEALTH NET COMMERCIAL CLAIMS Health Plan Services HEALTHASPEX C/O MCA ADMIN HealthMarkets Care Assured Healthscope HIGHLANDS WELLMONT HEALTH HOME TOWN AMS/CHANDLER GROUP HUMANA CLAIMS Humana Vision Care Plan Integra BMS KANAWHA HEALTHCARE SOLUTIONS KANAWHA HEALTHCARE SOLUTIONS LIFEWISE HEALTH PLAN OF OREGON March Vision MAS Benefits MAS Benefits MCA Administrators MEDCO HEALTH SOLUTIONS MEDICAID GOVT BENEFIT MEDICARECOMPLETE UNITEDHEALTHC Mediplus MERITIAN HEALTH MOUNTAIN STATES HEALTH ALLIANC MUTUAL OF OMAHA MVP health care National Union Fire Insurance Nippon Life Benefits NORTH AMERICAN NORTH AMERICAN ADM NovaNet OPTICARE PALMETTO PHP TENN CARE Plan Administrators Inc POMCO GROUP Preferred Care Preferred One Community Healthcare PREFRERRED HEALTH PARTNERSHIP Primary Care Physicians Prime Health Services PRINCIPAL LIFE INS PRIVATE HEALTHCARE SYSTEMS PROFESSIONAL CLAIMS MANGT INC PYRAMID CLAIMS QMB RAILROAD MEDICARE Retiree Medical Insurance RSL Speciality Products Admin S&S HEALTHCARE STRATEGIES SE Pipetrades Secure Horizons Medicare Complete SECUREHORIZONS DIRECT SELF INSURED SERVICES COMPANY SISCO SITE ASSISTANCE INTERNATIONAL SOUTHERN HEALTH SERVICES SPECTERA STANDARD LIFE State Farm State of Tennesse Medicaid SULLIVAN COUNTY JAIL SummaCare Sun Life Financial SUPERIOR VISION PLAN TENNCARE JOHN DEERE THE J.P. FARLEY CORPATION THE MAIL HANDLERS BENEFIT PLAN THE MEGA LIFE &HEALTH INS CO THE PYRAMID LIFE INS CO TLC laser clinic TN ANTHEM TN BLUE TN MEDICARE Todays Options Pyramid TradeBank TRICARE SOUTH REGION CLAIMS RE UFCW UNIONS UHC rivervalley-Americhoice UMR UMWA CAREMARK UNICARE USA MCO UNITED AMERICAN INSURANCE United Commercial Travelers of America United Healthcare River Valley United Healthcare River Valley 95378 UNITEDHEALTHCARE USA-MCO VALUE PLAN VISION SERVICE VETERANS ADMINISTRATION Virginia Medicare VISION BENEFIT OF AMERICA VISION CARE PLAN VISION SERVICE PLAN VISION USA Washington County Benefits WAUSAU BENIFETS WEBTPA WellCare Wells Fargo Windsor
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AARP Health Care Options AARP HEALTH CARE OPTIONS ACORDIA NATIONAL Advantra Freedom ADVANTRA FREEDON/PUBLIC EMPLOY AETNA Alliance for Business Training ALLIANCE PPO Allied ALTERNATIVE BENEFIT PLANS. American Continenetal Insurance Company AMERICAN HEALTH GROUP AMERICAN HEALTHCARE ALL / PHP AMERICAN HERITAGE LIFE INS CO AMERICAN PIONEER Amerigroup Railroad Retirement Board AMERIHEALTH ADMINSTRATORS Ameritas AMMARS INC ABA CLAIMS DEPT ANTHEM BLUE CROSS APWU Health Plan ASSOCIATED ADMINSTRATOR ASSURANT HEALTH TIME INS CO AVMA Group Health AVMA GROUP HEALTH & LIFE INS BAKERY AND CONFECTIONARY UNION BANKERS LIFE AND CASUALTY CO.Q Beechnut Street Benefit Management Services BLUE CARE Brotherhood Mutual Caremark CARITEN PREFERRED Cariten Senior Health CDS GROUP HEALTH CENTRAL STATES CHAMPVA CIGNA HEALTH CARE CLARITY VISION CLARITY VISION CM ADIMINISTRATORS COLE VISION Commerce Benefits Group Conseco Insurance Company CONTINENTAL LIFE INS CORPORATE SYSTEMS ADMIN. Coventry Health Care CrestPoint Health DAVIS VISION DEFINITY HEALTH DeltaUSA DMERC CARRIER Emeritus EMPLOYEE PLANS , LLC EYE MED Federated Mutual Fidelity Security Life Insurance FISERV HEALTH Flightcare FORTIS INSURANCE COMPANY GE FINANCIAL EMPLOYER SERVICES GEHA GM-SOUTHWEST Golden Rule Insurance Company GREAT-WEST LIFE &ANNUITY INS. Great American Life Guarantee Trust Life Guardian Group Medical Claims Hammerman and Gainer Harrington Health Harrington Helth HEALTH NET COMMERCIAL CLAIMS Health Plan Services HEALTHASPEX C/O MCA ADMIN HealthMarkets Care Assured Healthscope HIGHLANDS WELLMONT HEALTH HOME TOWN AMS/CHANDLER GROUP HUMANA CLAIMS Humana Vision Care Plan Integra BMS KANAWHA HEALTHCARE SOLUTIONS KANAWHA HEALTHCARE SOLUTIONS LIFEWISE HEALTH PLAN OF OREGON March Vision MAS Benefits MAS Benefits MCA Administrators MEDCO HEALTH SOLUTIONS MEDICAID GOVT BENEFIT MEDICARECOMPLETE UNITEDHEALTHC Mediplus MERITIAN HEALTH MOUNTAIN STATES HEALTH ALLIANC MUTUAL OF OMAHA MVP health care National Union Fire Insurance Nippon Life Benefits NORTH AMERICAN NORTH AMERICAN ADM NovaNet OPTICARE PALMETTO PHP TENN CARE Plan Administrators Inc POMCO GROUP Preferred Care Preferred One Community Healthcare PREFRERRED HEALTH PARTNERSHIP Primary Care Physicians Prime Health Services PRINCIPAL LIFE INS PRIVATE HEALTHCARE SYSTEMS PROFESSIONAL CLAIMS MANGT INC PYRAMID CLAIMS QMB RAILROAD MEDICARE Retiree Medical Insurance RSL Speciality Products Admin S&S HEALTHCARE STRATEGIES SE Pipetrades Secure Horizons Medicare Complete SECUREHORIZONS DIRECT SELF INSURED SERVICES COMPANY SISCO SITE ASSISTANCE INTERNATIONAL SOUTHERN HEALTH SERVICES SPECTERA STANDARD LIFE State Farm State of Tennesse Medicaid SULLIVAN COUNTY JAIL SummaCare Sun Life Financial SUPERIOR VISION PLAN TENNCARE JOHN DEERE THE J.P. FARLEY CORPATION THE MAIL HANDLERS BENEFIT PLAN THE MEGA LIFE &HEALTH INS CO THE PYRAMID LIFE INS CO TLC laser clinic TN ANTHEM TN BLUE TN MEDICARE Todays Options Pyramid TradeBank TRICARE SOUTH REGION CLAIMS RE UFCW UNIONS UHC rivervalley-Americhoice UMR UMWA CAREMARK UNICARE USA MCO UNITED AMERICAN INSURANCE United Commercial Travelers of America United Healthcare River Valley United Healthcare River Valley 95378 UNITEDHEALTHCARE USA-MCO VALUE PLAN VISION SERVICE VETERANS ADMINISTRATION Virginia Medicare VISION BENEFIT OF AMERICA VISION CARE PLAN VISION SERVICE PLAN VISION USA Washington County Benefits WAUSAU BENIFETS WEBTPA WellCare Wells Fargo Windsor
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

GENERAL: Fever, Weight loss, Weight gain, Fatigue

None Fever Weight gain Weight Loss

INTEGUMENTARY: Growths, Rashes, Acne

None Excema Psoriasis Growths Rash Acne Warts

NEUROLOGICAL: Headaches, Migraines, Seizures

None Headache Migraines Seizures Numbness, paralysis Multiple sclerosis

ENDOCRINE: Thyroid, Diabetes

None Hypothyroid Hyperthyroid Diabetes

EAR, NOSE, MOUTH, THROAT: Allergies, Sinus, Cough, Dry Mouth/Throat

None Allergies Hay fever Sinus Problems Runny Nose Chronic Cough Dry Throat / Mouth Hard of Hearing Post-nasal drip

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD

CARDIOVASCULAR: Hypertension, Heart Surgery, Vascular Disease

None Diabetes Heart Pain Hypertension Vascular Disease Heart Disease High Cholesterol

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Irritable bowel syndrome

GENITOURINARY: Kidney Stones, Frequent Urination, Impotence, BPH

None Painful urination Frequent urination Impotence BPH Kidney stones

MUSCULOSKELETAL: Athritis, Joint Pain, Head or Neck Injury

None Rheumatoid Arthritis Muscle pain Arthritis Joint pain Stiffness Swelling Cramps Osteoporosis Osteopenia

HEMATOLOGIC/LYMPHATIC: Anemia, Bleeding problems

None Anemia Bleeding

ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Allergy Shots

None Sneezing Swelling Redness Itching HIV Hives Lupus Lyme Disease Sarcoidosis Guillain-Barr? syndrome

PSYCHIATRIC: Depression, Anxiety, Insomnia

None Anxiety Depression Insomnia ADD ADHD Bi-polar disorder

EYES

None loss of vision blurred vision distorted vision loss of side vision double vision dryness mucous discharge redness sandy/gritty feeling itching burning foreign body sensation excess tearing/watering glare/light sensitivity eye pain or soreness infection styes flashes/floaters tired eyes

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