Clymer Healing Center Woodlands Healing Research Center

5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099

5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034

Demographic Identification Form

 
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A. PATIENT INFORMATION: All information herein contained is Confidential.
Last Name: First: Middle Initial:
Street Address:
Address con't:
City: State:PA,NJ, Other: Zip:
Soc Sec #: Gender:F M Date of Birth:
Home Phone: Home Fax:
Cell Phone: E-mail:
Occupation: Self Employed Student  Retired
Employer: Work Phone: Work Fax:
  Street Address:
  City: State:PA,NJ, Other: Zip:
     

B. Check all that apply:

 Minor Single Divorced   Widowed
Married,

 Spouse:

 Last: First:
Spouse Cell Ph#:        
Spouse Employer: Wk Phone: Wk Fax:
  Street Address:
  City: State:PA,NJ, Other: Zip:
 
If Minor OR You Want to Designate your Mother as an Emergency Contact:
  Mother's First Name: Last:
Street Address: Same in "A" above Other:
City: State:PA,NJ, Other: Zip:

Phone:

Cell:

    
Employer: Work Phone: Work Fax:
  Street Address:
  City: State:PA,NJ, Other: Zip:
 
If Minor OR You Want to Designate your Father as an Emergency Contact:
  Father's First Name: Last:
Street Address: Same in "A" above Other:
City: State:PA,NJ, Other: Zip:

Phone:

Cell:

    
Employer: Work Phone: Work Fax:
  Street Address:
  City: State:PA,NJ, Other: Zip:
 
 

Emergency Contact:

 Relationship to other Emergency Contact:

First Name:

 Last:
 Address:
City: State:PA,NJ, Other: Zip:
Home Phone: Work Phone: Cell: Phone:
 
C. Responsible Party (Name of Person Responsible for this account):
Relationship to Patient: FatherMotherOther:  
Date of Birth: Social Security#:
Street Address: Same in "A" above
City: State:PA,NJ, Other: Zip:
Employer: Work Phone: Work Fax:
Is this person (responsible party) currently a patient of Woodlands Healing Research Center? Yes No
 
D. Primary Insurance Carrier: Phone:
Group#: Policy#: Deductible Amount,$:
  Street Address:
  City: State:PA,NJ, Other: Zip:
Secondary Insurance Carrier: Phone:
Group#: Policy#: Deductible Amount,$:
  Street Address:
  City: State:PA,NJ, Other: Zip:
E. Other: Please check all that apply      
I was referred by: I wanted to come My spouse/family insisted My friends insisted
Is your problem: The subject of legal proceedings Accident Related Workers’ Compensation case
Disability Claim (if checked, also answer the following):
I have filed for disability I plan to file a claim for disability
Under a private program Under Government (Social Security or Title 19) program
G. Pharmacies & Other Doctors/Healing Arts Practitioners: List the pharmacies that your prefer to use and include their address phone and fax. Include your ID # if you have a mail order pharmacy.
Pharmacy #1:

 

 Street:
City: St: Zip:
Phone: Fax:
Pharmacy #2:

 
Street:
City: St: Zip:
Phone: Fax:
Mail Order Pharm:

ID #:

 Street:
City: St: Zip:
Phone: Fax:
 

List the names, addresses, phone and fax numbers (if known) of referring physicians, other doctors, chiropractors, psychologists, nutritionists and others helping you with your health care:

Provider Name (/MD/DO/DC, etc) Type of Practice Address/Phone/Fax
Street:
City: St: Zip:
Phone: Fax:
Street:
City: St: Zip:
Phone: Fax:
Street:
City: St: Zip:
Phone: Fax:
Street:
City: St: Zip:
Phone: Fax:
Street:
City: St: Zip:
Phone: Fax:
Street:
City: St: Zip:
Phone: Fax:
       
 To the best of my knowledge all of the information stated on this form is true.
Date:

 

Signature of person completing this page:

 

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