Doctors Office Patient Form

A doctor’s office patient form is a form filled up in a doctor’s office when the patient pays a visit to the doctor for a medical check-up or a medical treatment.  The form records the details of the patient like the contact details, medical history of the patient and other information like the details of insurance policy of the patient and the treatment that he has gone through under the doctor.

Sample Doctor’s Office Patient Form

                                                          Doctor Henry’s Clinic

Address: Medical Check-up Building,

41 York Shire Road,

Atlanta, North Dakota.

Phone number: 451235

Clinic timings: 9 A.M. to 9 P.M.

Patient Information

Name: ___________ First __________ Middle ________ Surname

Title (tick the appropriate one):  Mr.  Mrs. Miss. Ms.

Are you a student: Yes  No

If yes, are you a:  Full time student                 Part time student

Date of birth: ____________/__________/____________       Age: ___________

Gender(tick the appropriate one):  M        F

Address: __________________ Street ________________ City ____________ State ___________ Zip code

Residential phone number: ________________

Office phone number: _____________________

Mobile phone number: __________________

E mail id: _____________________

Select the one that is applicable to the patient:

Full time employed          Part time employed           Self-employed        Retired

Homemaker         Unemployed

If employed:

Name of employer: ______________

Designation: ____________________

Health or Medical Insurance Details

Select the appropriate one:   Group insurance            Personal insurance

Name of insurance company: ________________

Name of the plan: ________________

Policy number: ______________

Policy expiry date: ____________________

Acknowledgement of Notice of private practices:

Yes, I have read the NPP explained to me at the doctor’s office.

Financial release:

I assign Doctor Henry’s Clinic insurances benefit for services rendered to me.

Patient’s signature: ____________

Dated: __________

Category: Office Forms