Bey Acupuncture Patient Confidential Information
Part A: Confidential Information
Part B: Case History
Part C: Financial Arrangements
Part D: Insurance Information
Part A: Confidential Information
Date: *
Your answer
Last Name, First Name *
Your answer
Address *
Street, City, State, Zip
Your answer
Home Phone/Cell Phone *
Your answer
Email *
Your answer
Age *
Your answer
Date Of Birth *
Your answer
Sex *
Marital Status *
Social Security Number
Your answer
Drivers License Number *
Your answer
Occupation *
Your answer
Employer *
Your answer
Employers Address *
Street, City, State, Zip
Your answer
Part B: Case History
Chief Complaint *
Your answer
Complaint result of: *
Required
Date of accident/injury/other
Your answer
Have you seen any other doctor about this condition?
If yes, when?
Your answer
Doctor's Name
Your answer
Doctor's Address
Your answer
Have you had recent X-Rays?
If yes, when, and what area
Your answer
Spouse's name
Your answer
Occupation
Your answer
Employer
Your answer
Phone
Your answer
Nearest relative not living with you *
Your answer
Address *
Street, City, State, Zip
Your answer
Phone *
Your answer
In case of emergency, call *
Name
Your answer
Phone *
Your answer
For Females
Are you Pregnant?
Your answer
If Yes, How Long?
Your answer
Are you a minor? *
Required
If you answered yes, Please List both parents names and addresses *
Street, City, State, Zip
Your answer
Part C: Financial Arrangements
How do you plan to handle your account? *
Required
Part D: Insurance Information
Do you have a personal, group health or accident insurance? *
Required
If yes, give Company Name
Your answer
Subscriber Name
Your answer
Group Number
Your answer
I have read the above information and certify it to be true and correct to the best of my knowledge and belief and herby authorize this office to do whatever is necessary, in accordance with the state statutes, for the care and management of this complaint. *
Date
Your answer
Patient's Signature *
Sign Here
Your answer
Referred By
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