AMARILLO FAMILY PHYSICIANS CLINIC, P.A.
MEDICAL RECORD #_____________________________ DATE_________________
PATIENT INFORMATION
SOCIAL SECURITY # _____ — _____ — ____ DATE OF BIRTH _____/_____/_____
LAST NAME _______________________ FIRST/MIDDLE ______________________
ADDRESS ______________________________________________________________
CITY_____________________ STATE____________________ ZIP CODE _________
HOME PHONE # ___________ WORK PHONE # ___________ CELL# ____________
SEX M
F
EMAIL ADDRESS _____________________________________
PATIENT EMPLOYER___________________ HOW LONG EMPLOYED __________
DOCTOR: BRAVO BRISTER
BRITTEN BRYAN CALDWELL CARRUTH
HALE
SPURLOCK STEVENS TYSON WHELCHEL
MARITAL STATUS:
S
M
D
W
HOW DID YOU HEAR ABOUT OUR CLINIC?________________________________
HAVE YOU BEEN SEEN IN THIS CLINIC BEFORE? Y
N
IF YES, WHEN? _______________________________
FAMILY INFORMATION
IN THE COMPUTER WE LINK FAMILY MEMBERS TOGETHER IN ONE FAMILY
ACCOUNT, PLEASE LIST OTHER IMMEDIATE FAMILY MEMBERS THAT ARE
PATIENTS HERE:
________________________________________________________________________
IF PATIENT IS A MINOR
MOTHER ___________________________ \FATHER
___________________________
INSURANCE INFORMATION
(PLEASE PRESENT YOUR CARD)
PRIMARY INSURANCE __________________________________________________
CARDHOLDER’S NAME _______________ SOCIAL SECURITY # ______________
RELATIONSHIP OF CARDHOLDER TO PATIENT: SELF
SPOUSE
CHILD
IS CARDHOLDER A PATIENT AT THIS CLINIC?
Y
N
SECONDARY INSURANCE_______________________________________________
CARDHOLDER’S NAME _______________ SOCIAL SECURITY # ______________
_________________________________
PATIENT SIGNATURE