General Information Form

Patient name (first, middle, last)       _______________________________________     Date of birth   _______/_______/______   

Social Security number_______________________

 Address _______________________________________________________________    E-mail address______________________________

Employer    Name______________________________Address_____________________________________   Phone _______________

If patient is a student, name of school___________________________________________________________________________

Primary Care Physician    Name______________________________  Address_________________________________

Phone_______________

If you were referred by a doctor, who was this?____________________________________________________

In case of emergency, notify    Name ________________________________  Relationship _____________   

Phone ____________________

Pharmacy   Name__________________________________  Address________________________________ Phone  _________________

INSURANCE INFORMATION- PRIMARY INSURANCE POLICY HOLDER

Name ___________________________  Relationship________________  Social Security # _____________________

Address__________________________________________   Phone _____________________________

Date of birth _____/______/_______      Employer ________________________________________

In the event that this claim is denied by my insurance company, I understand that I am responsible for all charges

incurred as a result of this visit. I authorize the release of information to my insurance carrier (and, for worker's

comp, to my employer). I authorize paymentdirectly from my insurance carrier to Lone Star Orthopedics, P.A.

for surgical and medical care performed for the patient. I understandthat this authorization does not release

me from personal responsibility for payment of all charges. 

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________________________________________                                 ________/________/__________

Signature of patient or guardian                                                             DATE