New Patient Intake Form | Buckhead Rheumatology, Atlanta

Patient registration

Contact, guarantor, emergency and insurance details.

Patient information

Full legal name (first, middle, last, suffix)

Nickname

Sex

Date of birth

Social security number

Race

Preferred language

Ethnicity

Marital status

Complete mailing address

Street, city, state, ZIP code, county

Cell phone number

I do not have a home phone

Home phone number

Work number

Employment status

Retirement date (if retired)

Employer name

Employer phone number

Employer complete address

Street, city, state, ZIP code

Spouse or guarantor information

Responsible party. Check the box below if this is the same as the patient.

Same as patient

Full legal name (first, middle, last, suffix)

Date of birth

Social security number

Relation to patient

Sex

Home phone number

Cell phone number

Work number

Mailing address different from patient?

Employment status

Retirement date (if retired)

Employer name

Employer phone number

Employer complete address

Street, city, state, ZIP code

Emergency contact information

Name (first, last)

Relation to patient

If other, please specify

Home phone number

Cell phone number

Work number

Complete mailing address, if different from patient

Insurance information

Please bring your insurance card and a photo ID to your appointment.

Self-pay (no insurance)

Primary insurance

Patient relation to subscriber

Secondary insurance

Patient relation to subscriber

Prescription / Rx provider

If different from insurance carrier

Full name of subscriber

Complete below if different from patient, spouse or guarantor

Subscriber date of birth

Employment status

Retirement date (if retired)

Employer name

Employer size

Employer complete address

Street, city, state, ZIP code

Care preferences

Primary care physician

Do you want anyone to know you are here?

	Major medical problems	If deceased, cause
Maternal grandmother
Paternal grandmother
Maternal grandfather
Paternal grandfather
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Child 1
Child 2
Child 3

Fill it out at home.
Print it and bring it with you.

Patient registration

Medical / social history

We schedule by phone or physician referral.

	Operation	Date	Hospitalization	Date
1
2
3

Fill it out at home.Print it and bring it with you.

We schedule by phone or physician referral.

Fill it out at home.
Print it and bring it with you.