ETSU Student/University Health Services
Patient Information Sheet
(PLEASE PRINT IN INK!)
Name:
E#:
Last
Maiden
Local Address:
First
Street/Building
MI
City
Campus PO Box #:
Cell #:
State
Date of Birth:
Home Address:
(If different from above) Street
Emergency Contact Person:
Zip
Sex:
City
State
Relationship:
Social Security #
Zip
Local Phone #
M
F
Home Phone #
Phone:
List any allergies:
Where does patient live?
Do you have medical insurance?
Lives on campus (1)
Y es
Liv es off campus (2)
No
Faculty/Staff
Provider:
Plan Number:
(We currently do not file insurance for students)
Ethnicity: (This information is voluntary and may be used for research purposes.)
Do you smoke?
Pacific Islander (D)
Hawaiian (H)
Y es
White, or Whites of Hispanic Descent
Native American(E)
More than one race (I)
No
Asian (C)
Native Alaskan (F)
Other (J)
Black, African Amercan (A)
Marital status of patient:
Married
Single
Are You A Veteran?
Y es Which Branch?
No
Student Status:
Separated
Divorced
Widowed
Full-time
Part-time
Faculty
Staff
Encumbrances for charges: By signing below, I understand that I may incur charges for special laboratory or other
services provided by the ETSU Student/University Health Clinic and that I am assuming responsibility to pay any and
all charges posted to my account. There will be a $30 non-refundable charge for any checks returned as non-payable
from my financial institution. (PATIENT’S SIGNATURE:
)
Provision of care: Student/University Health Services is a nurse-managed clinic. I realize that my care will be provided by Advance
Practice Nurses, Registered Nurses, and CMA’s. Referral to the physician preceptor will be available on an individualized basis.
For Students Only: I understand that my student records may be encumbered by the Student/University Health Clinic and that I will
need to reimburse the clinic for those charges to remove any hold that has been placed on my record.
This clinic is a teaching facility. Students, under the supervision of faculty, may be
scheduled to participate in your care. Please notify the receptionist if you do not
wish to all0w a student’s involvement in your care during today’s visit.
My right to prepare advance directives (directives about what medical treatment I
may want to receive if I became physically or mentally unable to communicate my
wishes) has been explained to me.
Signature of patient or parent (if minor)
Date:
4/30/12js
Witness