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The safety of your account identification information is taken very seriously, only stored in encrypted formats, and handled over secure connections. This form is in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Patient Demographics
Please note, some of this information is mandated by the federal government. We ask that you respectfully answer all of the questions.
The items with the (*) must be answered to move forward and submit the form.
Are you a NEW PATIENT or has it been OVER ONE YEAR since your last visit?
(If you have already filled the online forms out since scheduling your appointment, please disregard)
*
YES
NO
If you answered NO; please disregard and exit out.
Updated forms are needed yearly, if you have not filled out forms recently, you will be asked to do so. If we need additional information; we will let you know at your appointment check-in.
Which office is your appointment scheduled at?
*
Hoover
Anniston/Oxford
I do not have appointment scheduled
Please call our office to schedule your appointment.
*
First Name
*
Last Name
*
Nickname
Marital Status
*
Single
Married
Widowed
Divorced
Separated
Drivers License Number
(optional)
You may upload a copy of your drivers license.
(optional) We will need a copy on file, make sure to bring to your appointment if you do not upload.
Social Security Number
Date of Birth
*
+
65 or Older?
*
Yes
No
Sex at Birth
*
Male
Female
Preferred Language
*
English
Spanish
Other
Ethnicity
*
Non-Hispanic
Hispanic
Declined to Specify
Race
*
Asian/Asian American
Black/African American/African
Native American/Native Alaskan
White/Caucasian/European American
Other
Emergency Contact Name
(other than self)
Emergency Contact Phone Number
Relationship to Emergency Contact
*
Parent
Spouse
Other
Name of Patient's Spouse
Spouse's Phone Number
Preferred Method of Contact
Cell Phone
Alternate Phone
Email
Text
Patient's Preferred Phone Number
*
Preferred Phone
*
Cell
Home
Other
Ok to Leave a Message?
*
Yes
No
Alternate Phone Number
Alternate Phone
Cell
Home
Other
Email Address
Home Address
*
City, State
*
Zip
*
Drivers License Number
(optional)
Employment
*
Employed
Retired
Student Full Time
Student Part Time
Other
Patient's Employer
Work Phone Number