Client Demographics Form

Client Demographics Form
Name

First NameLast Name
Client ID
Sex

MaleFemaleOther
Date of Birth

MonthDayYear
Date
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Email
example@example.com
Would you like to receive appoint reminders? Please select an option

EmailText message
Client is a minor

YesNo
Parent Information
Mother's Name

First NameLast Name
Mother's Phone Number

Area CodePhone Number
Father's Name

First NameLast Name
Father's Phone Number

Area CodePhone Number
Are parents married?

YesNo
Parent's Address (If Different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Emergency Contact Email Address
example@example.com
Relationship with Emergency Contact
Insurance Information
Insurance Company
Member ID
Group ID
Plan ID
Client's Relationship to Insured

ClientClient's SpouseClient's ParentOther
Picture of Front of Insurance Card
Picture of Back of Insurance Card
Do you have a secondary insurance plan?

YesNo
Insurance Company
Member ID
Group ID
Plan ID
Front of Secondary Insurance Card
Back of Secondary Insurance Card
Client's Relationship to Primary Insured

ClientClient's SpouseClient's ParentOther
Name of Primary Insured

First NameLast Name
Birthday of Primary Insured

MonthDayYear
Date
Address of Primary Insured

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Picture of Front of Insurance Card
Picture of Back of Insurance Card
Should be Empty:

Client Demographics Form

Parent Information

Emergency Contact Information

Insurance Information