PATIENT INFORMATION RECORD  (PLEASE PRINT)                        DATE__________________

NAME:  LAST_____________________________FIRST__________________MIDDLE_______________

MARITAL STATUS (circle one) S M W D SEP  BIRTHDATE_______________________AGE_________

ADDRESS_______________________________________________________________________________

                                    Street                                                 City                                State                Zip Code

HOME PHONE___________________CELL PHONE_________________ E-MAIL ____________________

EMPLOYER________________________________OCCUPATION________________________________

                                                                                                                        (indicate if student)

EMP. ADDRESS__________________________________________________________________________

                                    Street                                                 City                                State                Zip Code

SPOUSE’S NAME________________________BIRTHDATE_____________CELL PHONE______________

SPOUSE’S EMPLOYER____________________________OCCUPATION___________________________

                                                                                                                                    (indicate if student)

EMP. ADDRESS__________________________________________________________________________

                                    Street                                                 City                                State                Zip Code

NAME OF SPOUSE IF DIVORCED OR SEPARATED___________________________________________

ADDRESS________________________________________________________________________________

                                    Street                                                 City                                State                Zip Code

HOME PHONE___________________CELL PHONE_________________ E-MAIL ____________________

IF PATIENT IS A MINOR OR STUDENT, PLEASE FILL IN BELOW; OTHERWISE GO TO THE NEXT SECTION

MOTHER’S NAME_________________________________ BIRTHDATE____________________________

ADDRESS________________________________________________________________________________

                                                   Street                                    City                             State                 Zip Code

HOME PHONE___________________CELL PHONE_________________ E-MAIL ____________________

MOTHER’S EMPLOYER_______________________________________OCCUPATION________________

ADDRESS________________________________________________________________________________

                                                   Street                                    City                             State                 Zip Code

FATHER’S NAME__________________________________ BIRTHDATE____________________________

ADDRESS________________________________________________________________________________

                                                    Street                                    City                             State                 Zip Code

HOME PHONE___________________CELL PHONE_________________ E-MAIL ____________________

FATHER’S EMPLOYER_________________________________________OCCUPATION_______________

ADDRESS________________________________________________________________________________

                                                   Street                                    City                             State                 Zip Code

PLEASE COMPLETE THE INFORMATION BELOW AND GIVE YOUR INSURANCE CARD AND DRIVER’S LICENSE TO THE RECEPTIONIST

EMERGENCY CONTACT INFORMATION (SOMEONE NOT LIVING AT THE SAME ADDRESS):

NAME____________________RELATIONSHIP___________ PHONE: HOME_________CELL___________

ADDRESS________________________________________________________________________________

                                                 Street                                      City                             State                 Zip Code

NAME OF PREFERRED PHARMACY_______________________ PHONE NUMBER__________________

ADDRESS________________________________________________________________________________

                                                 Street                                      City                             State                 Zip Code

NAME OF PRIMARY PHYSICIAN__________________________ PHONE NUMBER__________________

ADDRESS________________________________________________________________________________

                                                 Street                                      City                             State                 Zip Code

CO-PAYMENTS AND ANY CHARGES NOT COVERED BY YOUR INSURANCE ARE TO BE PAID AT THE TIME THE SERVICES ARE RENDERED.  PLEASE NOTIFY THE RECEPTIONIST IF YOU HAVE ANY QUESTIONS.

THANK YOU FOR CHOOSING THE ALLERGY & ASTHMA CENTER OF MICHIGAN.