Heritage Family Medicine

Patient Information

Patient Full Name *

First, Middle, Last Names

Social Security Number

Patient Date of Birth *

Email Address *

This is important for communication.

Mailing Address, Complete *

Street name and number, City, State, Zip Code

Cell Phone

Home Phone

Work Phone

How should we contact you?

Cell Phone

Home Phone

Work Phone

Emergency Contact

Name, Relationship, Phone

Preferred Pharmacy

Name and Town

Insurance

Insurance Company *

Responsible Person on Insurance Card *

Responsible Person's Date of Birth *

Employer Name and Phone *

Policy Number *

See your insurance card, write none if no insurance. Add a "/" for secondary plan number

Group Number *

See your card

Co-Pay/Deductible *

If you don't know these, please call your insurance. We need this for first visit.

Secondary Insurance

Do you have another insurance, perhaps a spouse or family member?

How did you hear about Heritage Family Medicine *

Friend or Relative

Insurance Plan

Online Search

Walk In / Sign

Other

I understand the following:

*Please note: individuals seeking treatment from our office are not considered active patients until the practice has completed an assessment of the individual at an office visit and thereafter notifies the individual of being accepted as a patient. Please understand that simply making an appointment or filling out paperwork is not adequate to establish a patient-physician relationship. A School Bus or Commercial Driver's Exam does not in any way imply that this practice is taking on responsibility for the patient's medical problems. Any problems uncovered should be taken up with a patient's primary medical doctor, and followed thereafter.

Heritage Family Medicine

Available Forms

Demographics

Patient Information

Insurance