Columbus Medical Clinic 2122 Hwy 71 S, Ste 101 Columbus, TX 78934 If this is a work related injury, please notify the receptionist prior to completing this form. Patient Information Please Print Today’s Date Name First Middle Last Suffix Maiden Mailing Address City Zip Physical Address City State Zip Gender Male Female Social Security # □ □ Marital Status Single Married Date of Birth □ □ □Divorced □Separated □Widowed Race Decline American Indian Pacific Islander Asian White/Hispanic Other □ □ □ □ □ □ □ Ethnicity Decline Hispanic Not Hispanic □ □ □ Primary Language Primary Physician Please Put at least one phone number Home Email Work Preferred Phone Home Cell Work □ □ □ Cell Preferred Contact Method Phone Email Mail □ □ □ Guarantor Information Responsible Party First Middle Last Suffix Maiden Relationship Self Spouse Parent Guardian Gender Male Female □ □ □ □ □ □ □ Date of Birth Social Security # Address City State Zip Home Phone Cell phone If applicable, please provide the receptionist with your insurance card(s) to be scanned in the computer.
Columbus Medical Clinic 2122 Hwy 71 S, Ste 101 Columbus, TX 78934 If this is a work related injury, please notify the receptionist prior to completing this form. Patient Information Please Print Today’s Date Name First Middle Last Suffix Maiden Mailing Address City Zip Physical Address City State Zip Gender □ Male □ Female Social Security # Marital Status □ Single □ Married □Divorced □Separated □Widowed Date of Birth Race □ Decline □ American Indian □ □ Pacific Islander □ Asian □ White/Hispanic □ Other Ethnicity □ Decline □ Hispanic □ Not Hispanic Primary Language Primary Physician Please Put at least one phone number Home Email Work Preferred Phone □ Home □ Cell □ Work Cell Preferred Contact Method □ Phone □ Email □ Mail Guarantor Information Responsible Party First Middle Last Suffix Maiden Relationship □ Self □ Spouse □ Parent □ Guardian □ Gender □ Male □ Female Date of Birth Social Security # Address City State Zip Home Phone Cell phone If applicable, please provide the receptionist with your insurance card(s) to be scanned in the computer.
Demographics-English.docx