WESTSIDE INTERNAL MEDICINE, LLC
WESTSIDE INTERNAL MEDICINE, LLC
PATIENT INFORMATION
(Please Print)
Name: _______________________________________ Date of Birth: __________________ Age: __________
(Last) (First) (Initial)
Address: __________________________________________________________________________________
(Street) (City) (State) (Zip)
SEX: M F Marital Status: S M D W Social Security #: ___________________________
Home Phone: ______________________ Cell Phone: ________________________________
Employer: ______________________________________________ Work Phone: _____________________
Emergency Contact: _________________________________________________(___)___________________
(Name) (Relationship) (Phone)
Race: _________________ Hispanic Non-Hispanic Language Preferred: ______________________
Do you rely on transportation such as AmbuStar, Logisticare, etc.? Yes No
How did you hear about our practice? _________________________________________________________
Insurance? Name: ______________________ Member/Subscriber No.: _____________________________
Previous Primary Care Provider? Name: ___________________________ Phone: ______________________
Do you give permission to this office to leave a message regarding your appointments, medication and/or lab results?
Home Phone Yes No Cell Phone Yes No Initial _____________
Email: ___________________________________________________________________________________
I hereby consent to treatment by the physicians and/or associates of Westside Internal Medicine.
I hereby assign my insurance benefits to be paid directly to Westside Internal Medicine. I understand that I am financially responsible for all charges not covered by the assignment. Submitted New Patient paperwork does not constitute a Physician-Patient Relationship. All patients must be seen by one of our Providers to establish a Physician-Patient Relationship.
Signature: ________________________________________________ Date: _____________________
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