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Patient Number:
Last Name:   First Name & Initial:
Address Line 1:
Address Line 2:
City:	State: Alaska Alabama Arkansas Arizona California Colorado Connecticut District Of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming	Zip:	Home Phone:
Date of Birth:	Sex:   Marital Status: Married Single Widowed Divorced		Referred by:
Doctor:	Does your insurance company require pre-authorization? Yes No
Allergies, If Any:
Patient Soc. Sec. #:
Patient Employer:
Employer Address:
City:	State: Alaska Alabama Arkansas Arizona California Colorado Connecticut District Of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming	Zip:
Employer Phone:	Ext.:
Responsible Party Last Name: First Name & Initial:
Relationship:		Address:
City:	State: Alaska Alabama Arkansas Arizona California Colorado Connecticut District Of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming	Zip:	Home Phone:
Responsible Party Date of Birth:		Responsible Party S.S. No.:
Responsible Party Employer:
Employer Address:		Employer Phone:

Primary Insurance or Medicare Name:
Medicare or Insurance Address #1:		Medicare or Insurance Phone #1:
Policyholder Last Name:	First Name:	Relationship:
Certificate No.:	Group No.:	Member No.:
Insurance #2 Name:
Insurance #2 Address:		Insurance #2 Phone:
Policyholder Last Name:	First Name:	Relationship:
Certificate No.:	Group No.:	Member No.:
Names of everyone I consent to know about my appointments, prescriptions, records (like spouse):
I authorize Timberline Medical to leave a message at my home/cell number regarding medical information: Home Yes Cell Yes No
Spouse's Name:
Nearest Living Relative or Friend Not Living With You:

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