PATIENT INFORMATION
Last name *	First	Middle Initial	Preferred name
Today’s date	DOB	Legal Gender: (check one/see note bottom page)*	Pronouns:
M F

Street Address	City	State	Zip
Cell phone	Home phone	Work phone	Best # to reach you	Voicemail message OK?
Cell Home Work	Cell Home Work

Email	May we send you updates on our activities via email/mail?
Yes No

Occupation	Referred to clinic by	Who may we thank for referring you ?

EMERGENCY CONTACT
Name of relative or friend to contact in an emergency	Relationship to you
Cell phone	Home phone	Work phone

INSURANCE INFORMATION
Insurance Company Name	Insurance phone number
Policy ID / ID #
Insured’s name (if not you)	Relationship to Insured	Insured’s DOB (if not you)
Claim # if Accident/Injury	Date of Accident/Injury

*While the Academy recognizes a variety of genders/sexes, many insurance companies and legal entities do not. The name/gender you have listed must be the name used on documents pertaining to insurance billing and correspondence. If your preferred name and pronouns are different from these, please let us know.
Patient/Guardian Signature	Date signed