Pulmonary & Critical Care Consultants of Austin, LLP 1305 ...
嚜燕ulmonary & Critical Care Consultants of Austin, LLP
1305 West 34th Street #400, Austin, TX 78705
(512) 459-6599, FAX (512) 459-8496
PLEASE PRINT
NAME: _________________________________________________________________________
Last
First
MI
M
F
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PREFERRED NAME (if different from legal name):_______________________________________
ADDRESS____________________________________________ CITY____________________ ST______ ZIP CODE_____________
PRIMARY PHONE # ____________________________
Circle: home 每 work - cell
MAY WE LEAVE A MESSAGE? CIRCLE: Y - N
SECONDARY PHONE #_________________________
Circle: home 每 work 每 cell
MAY WE LEAVE A MESSAGE? CIRCLE: Y - N
EMAIL __________________________________________________
DOB _____________
AGE ________
EMPLOYER________________________________ SOCIAL SECURITY #_____________________ MARITAL STATUS: M
D
S
circle one
W
PHARMACY NAME _______________________________ LOCATION ____________________ PHONE ___________________
REFERRING PHYSICIAN ____________________________________________________________
Last
First
PRIMARY CARE PHYSICIAN
_____________________________________________________
Last
First
OTHER SPECIALISTS YOU SEE ________________________, ____________________________, ___________________________
*PRIMARY INSURANCE_______________________________________ Insured*s Name __________________ DOB ________
Example: Humana Medicare PPO
SECONDARY INSURANCE____________________________________ Insured*s Name __________________ DOB ________
Example: BCBS HMO
PERSON WE MAY CONTACT
REGARDING YOUR MEDICAL
CONDITION IN EMERGENCY
NAME: _______________________________ RELATIONSHIP: __________________
PRIMARY # _____________________
Circle: home 每 work - cell
SECONDARY # ________________________
Circle: home 每 work - cell
Persons we may inform or answer questions about your general medical conditions/diagnosis:
Contact ___________________________Relationship ________________Cell/Home _________________
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Contact ___________________________Relationship ________________Cell/Home _________________
circle one
___________________________________________________
Signature of Patient or Insured
__________________________
Date
PRIVACY NOTICE: I AKNOWLEDGE I HAVE RECEIVED A COPY OF THE PRIVACY NOTICE FOR PULMONARY & CRITICAL CARE CONSULTANTS OF
AUSTIN
___________________________________________________
Signature of Patient or Insured
__________________________
Date
P
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