Home Patient Demographic Form Patient Demographic Form Date* Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Please enter a value between 0 and 99.Is the patient a minor?*YesNoGender*MaleFemaleMarital Status*SingleMarriedDivorcedWidowedSeparatedSocial Security Number*Primary Phone Number*Cell PhoneEmail* Injury/Illness is due to*Auto AccidentOtherDate of Accident* State where the accident occured*Was the vehicle a Rental Car*YesNoDo you own a vehicle?*YesNoPatient Resides With*AloneSpouseParentsChildrenOtherDo any household family members own a vehicle*YesNoThe need for diagnostic testing and/or procedure has been thoroughly explained to me and I agree to have the testing performed in this office. I further understand my treating physician will arrange an acceptable payment plan for any cost not covered by my insurance. PLEASE PRESENT INSURANCE CARDS AND PHOTO ID TO THE RECEPTIONIST SO COPIES MAY BE MADE.Patient or Responsible Party Signature* I Agree (Terms and Conditions following) Date* I authorize the doctor and other health-care professionals (clinical staff) to perform diagnostic procedures and treatment as may be necessary for proper medical care. I authorize Kentucky Pain Associates to release any medical information including the diagnosis and the records of any treatment or examination rendered to me/my child during the period of such care to third party payers, and other entities and/or health practitioners. I authorize and assign directly to Kentucky Pain Associates all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.Patient or Responsible Party Signature* I Agree (Terms and Conditions following) Date* In order to help us stay within the guidelines of HIPAA, please list any person(s) that you authorize us to speak with about your medical condition. You do not need to list any of your physicians.NameRelationshipNameRelationshipNameRelationshipDo we have your permission to leave messages regarding information (such as appointment reminders or requests to call the office) when you are not at home?*YesNoDo we have your permission to call you at the listed secondary phone number?*YesNoDo we have your permission to email you with important information and/or periodic updates?*YesNoWe respect your privacy and will never share it with anyone.By signing below you agree that you have read the HIPPAA guidelines posted in the office. If you would like a copy of the guidelines one will be provided to you.Patient Name*Patient Signature* I agree Today's Date* NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.