NEW YORK UROLOGICAL ASSOCIATES, P.C.
Phone: 212-570-6800 Fax: 212-861-7964 Fax: 212-734-7425
PATIENT INFORMATION *PLEASE PRINT – DO NOT LEAVE ANYHTHING BLANK* LAST: ____________________________ FIRST: ___________________ MIDDLE _________________ ADDRESS: ___________________________________________________________ APT: ___________ CITY: HOME #: _______________________ OFFICE #: _________________________ EXT#: ____________ DATE OF BIRTH: ____/ ____/ ____ SEX: _____________ AGE: _____________ SOCIAL
SECURITY#: ______-_____-______ MOTHER’S
NAME: _________________________ FATHER’S NAME: ___________________________ MARITAL STATUS: ___________ SPOUSE NAME: __________________________________________ HOW DID YOU HEAR ABOUT OUR PRACTICE? ___________________________________________ HOW
WILL YOU BE PAYING TODAY? CASH___
CHECK___ CREDIT CARD____ PRIMARY CARE PHYSICIAN (PCP) DOCTOR’S FIRST & LAST NAME: ________________________________________________ PHONE: ________________ ADDRESS____________________________________________ MEDICAL INFORMATION LIST ALL ALLERGIES: _________________________________________________________ ____________________________________________________________________________ LIST ALL MEDICATIONS (CURRENTLY
TAKING):__________________________________ ____________________________________________________________________________ IN CASE OF EMERGENCY, CONTACT NAME & PHONE #: ____________________________________________________________________________ INSURANCE INFORMATION PRIMARY:
___________________________________________________________________ MEMBER ID #: _____________________________
GROUP/ACCOUNT #: ________________ NAME OF INSURED: ___________________________RELATIONSHIP:
_________________ DATE OF BIRTH: ____/ ____/ ____ SECONDARY:
________________________________________________________________ MEMBER ID #: _____________________________
GROUP/ACCOUNT #: ________________ NAME OF INSURED: ___________________________RELATIONSHIP:
_________________ DATE OF BIRTH: ____/ ____/ ____ WERE YOU
EVER ADMITTED TO THE FOLLOWING HOSPITALS? |