Name
NEW PATIENT INFORMATION SHEET
Age
Last
First
Middle
Address
City
State
Zip Code
Date of Birth
Sex
Marital
Status
 
 
Label
 
Children
Patient's SS #
Insured's Name
Insured's SS #
Insured's D.O.B.
Employer's Information
Company's Name
Company's Address
Company's Phone #
Home Phone #
Work Phone #
Cell Phone #
Driver's License
How did you hear about us?
 
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Referring Physician
Health Information
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Allergies to medication
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Medical Conditions
Give list to receptionist if you have one
Do You smoke?
How Much?
Do You Drink Alcohol
How Much?
I hereby authorize the release of any medical information necessary to process any claims.  I authorize the payment of medical benefits to Dr. De Freitas for all medical services rendered by him to me.  I understand that the service is provided to me and not the insurance company and I am therefore financially responsible for all charges whether or not my insurance covers such charges.
Signature
 
Date
Preferred pharmacy
Surgeries
Please Return This Form With Your Health Insurance Card and Driver's License To The receptionist
 
 
 
 
Email
Lifestyles
 
 
 
 
 
 
 
 
 
 
 
 
M
F
 
Married
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Junior De Freitas, M.D.
3324 Colorado Blvd, 103
Denton, TX 76210
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