Family Medicine Centers 
 
Please check one:    ______ New Patient
                                   ______ Updated Info
 
Patient Information
Name (Legal) First, Middle, Last Social Security No. Marital Status

Sex

 Birthdate
S/M/D/W

M/F
Address City, State, Zip Home Phone Social Security #
Employer                                                               Employer's Address (include City, State, Zip)         Work Phone             Driver's License #
Referred By: Cell # E-mail
Emergency Contact: (Not in same household)
Head of Household/ Spouse/ Guarantor Information
Name Sex

Relationship to Responsible Party

 Birthdate
M/F Spouse Child other
Address                                                                                          City, State, Zip                                      Home Phone              Social Security #
Employer                                                                         Employer's address (including City, State, Zip)           Work Phone              Driver's License #
Insurance Information Please present insurance card to Receptionist in addition to completing the area below.
INSURANCE: Company Name Identification Number                                      Group Number
Insurance Company Address (include City, State, Zip)
Name of policy holder (if not parent or guarantor) Date of Birth Relationship to policyholder
ADDITIONAL INSURANCE: Company Name Identification Number Group Number
Insurance Company Address: (Include City, State, Zip)
Name of policyholder (if not patient or guarantor)                   Date of Birth     Relationship to policy holder
Medicaid  Number
Additional Information
Were  you injured on the job?        Yes No Date:
Were you injured in an automobile accident? Yes No Date:
Consent to treatment: I voluntarily consent to receive medical and health care services provided by Family Medicine Center of Amarillo physicians, employees and such associates, assistants, and other health care providers as my physicians deem necessary. I understand that such services may include diagnostic procedures, examinations and treatment.

I request that payment of authorized insurance benefits be made on my behalf to the provider indicated above for any services furnished to me. I authorize any holder of medical information about me or my dependent to release to the insurance company any information needed to determine these benefits or the benefits payable for related services. A photocopy of this assignment is to be considered as valid as the original until revoked. I understand that I am financially responsible for all changes whether or not covered by said insurance.
Patient's/Guarantor's Signature:__________________________________________________Date:________________