Patient Information Sheet
Patient Information
Last Name First Name MI
Address City State
Home Phone Cell Work
Email Date of Birth Gender
Marital Status___Married ___Single ___Widowed ___Divorced ___Separated Social Security Number
Race ___American Indian ___Asian ___Black or African American ___Native Hawaiian ___White ___Other
Ethnicity ___Cambodian ___Filipino ___Hispanic/Latino ___Non-Hispanic
Dependent? If yes, Guardian’s Name
Address Phone
Responsible Party Address
City State Relationship to Patient
Employer
Employment Status ___Employed ___Self-employed ___Retired ___On active military duty ___Unknown
Employer Name Employer Address
Employer phone Position
Emergency Contact Information
Name Relationship to Patient
Home or Work Phone Cell Number
Insurance
Primary Insurance Carrier Address
Insured’s Name Relationship to Patient
Insured’s ID Number Group Number
Preferred Method of Contact
Preferred Method of Contact ___ Phone ___Email ___Patient Portal ___Other
Do we have your permission to leave a detailed message including test results? ___Yes ___No
Phone number to leave messages Email to leave messages
Signature
I verify that the above information is factual and true to the best of my knowledge. I understand that proof of insurance and/or copay,
if applicable, is due at the time of service.
Patient or Legal Guardian Signature Date
Patient Information Sheet, Continued
Pharmacy Information
Pharmacy Name Address
Pharmacy Phone Number
Authorization to Release Medical Information
Please check one
____ I authorize One to One to release my medical information including the diagnosis, examination rendered to me, treatment to:
____ Spouse_____________________ Child(ren)______________________Other_____________________________________
____ Information is not be released to anyone.
This release of information will remain in effect until terminated by me in writing.
General Consent to Treat
I consent to treatment by One to One Physicians and staff for my healthcare, including but not limited to exams, testing, medications,
and minor procedures. I acknowledge and agree no guarantees have been made to me as the results or outcome of my care. I
understand that State Law requires physicians to report certain communicable diseases to the Health Department.
If at any time I have questions about my examination, diagnosis, or treatment, I will not proceed until my questions have been
answered to that I am fully informed. I understand that giving the providers and nurses all relevant information is important to my
proper diagnosis and treatment. I understand complete compliance with my provider’s instructions is critical to the success of any
treatment prescribed.
I authorize one to one Health to release my health information to my health plan or to a health and wellness provider approved by my
health plan for purposes of advising me concerning appropriate measures to maintain or improve my health or any condition reflected
in my records. I authorize One to One Health to release information to my designated insurance plan for the purpose of health plan
administration, including receiving or making payment for services rendered on my behalf. I understand a patient is responsible for all
charges incurred, subject to contract and program rules, regardless of my insurance status. If it becomes necessary to send this
account to collections, the patient will be responsible for all additional charges.
_______________________________________ _____________
Patient Signature (or Parent/Guardian if a minor) Date
