Celina Medical Clinic

Patient Information

Please print clearly and complete all information requested.  This will ensure that your claim is being processed efficiently.  Thank you!

Patient Name ___________________________________________________________

Mailing Address ________________________ City__________ State ____ Zip_______

Home # __________________ Cell # ________________ Work # _________________

DOB ___________                  Sex:  M   F                   Marital Status:    M     S     D    W      

Social Security # ________________________

In case of emergency, please contact _______________________ Phone _____________

In the event we call to discuss medical information, please list whom we may we speak with:

______________________________________________________________________

______________________________________________________________________

Do you have advanced directives?     YES     NO                                

If yes, where are they kept? _____________________________________________________

Health Questionnaire

Surgeries and Illnesses

Year / Illness or Surgery    __________________________________________________

Year / Illness or Surgery    __________________________________________________

Medications (List all medications you are currently taking.  Include over the counter Rx as well.)

Name / Strength / How Often _______________________________________________

Name / Strength / How Often _______________________________________________

Name / Strength / How Often _______________________________________________

Name / Strength / How Often _______________________________________________

Drug Allergies___________________________________________________________

Medical History

Main Problems: 1.________________ 2. ____________________ 3.________________

Medical conditions in your family: __________________________________________

______________________________________________________________________

If we are filing with insurance please understand that by signing below, you agree you are financially responsible for whatever insurance does not cover. 

I have received the Notice of Privacy Practices and the Celina Medical Clinic Financial Policy and I have been provided an opportunity to review it. 

Name ________________________  Signature _______________________________

Date _________________________