Patient Profile (Demographics) Name* First Middle Initial 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 Cell Phone*Work PhoneHome PhoneEmail Weight*Height*Height in Inches*Date of Birth* MM DD YYYY AgeSexMaleFemalePrimary Insurance*Secondary InsuranceCardholder Name*Date of Birth* MM DD YYYY PhoneReferring ProviderPrimary Care ProviderPharmacy & Location (street name)Check List of Medical Problems, if any Diabetic Heart Disease Hypertension Afib Pacemaker CHF COPD Emphysema Memory Loss Seizure MS TIA Stroke Insomnia Chronic Pain Chronic Fatigue Fibromyalgia Depression Anxiety ADD ADHD PTSD Daytime Sleepiness Other OtherList any Current MedicationsPlease list all known DRUG ALLERGIESDo You Smoke?*YesNoI authorize the release of any medical information to process my insurance claim and authorize payment of medical benefits to my doctor for services rendered. I also authorize the use of photographs for medical purposes. I understand that payment is expected when services are rendered including co-payments from insurance companies.* I authorize and agree by checking this box and typing my name below Your Name*Date* Date Format: MM slash DD slash YYYY Check the box belowNameThis field is for validation purposes and should be left unchanged. Save and Continue Later Please bring the printed materials for office visit or you can fax it to 989-793-7113 or 989-792-1792.