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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.
Which office is your appointment scheduled at?
*
Birmingham
Anniston
Uncertain
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
Preferred Method of Contact
*
Cell Phone
Alternate Phone
Email
Text
Emergency Contact Name
(other than self)
Emergency Contact Phone Number
Name of Patient's Spouse
Spouse's Phone Number
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
*
Employment
*
Employed
Retired
Student Full Time
Student Part Time
Other
Patient's Employer
Work Phone Number