Transcription of PATIENT DEMOGRAPHIC INFORMATION FORM
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PATIENT DEMOGRAPHIC INFORMATION FORM
Office of Donald A. Smith, MD. 51 Locust Street, Unit #4. Northampton, MA 01060. Ph(413) 341-5081 Fax(413)-341-5082 Donald A. Smith, MD 2013 If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use a PATIENT portal system to send forms to be completed, and to send appointment reminders. If you have any reports for the Dr. Smith, we would appreciate them in advance. If you cannot get them to us by mail or fax in advance, please bring them with you to your appointment. PATIENT DEMOGRAPHIC INFORMATION FORM Today s Date_____ PATIENT INFORMATION : PATIENT s Name _____ Address _____ City_____State_____ Zip_____ Home Phone#_____Mobile/Cel.#_____Work#_____ **Please indicate preferable phone to use Age_____Date of Birth _____ Social Sec.
information protected under the requirements from the Health Care Information Portability and Accountability Act (HIPPA). The following conditions affect the confidentiality of your information: 1.) You may chose to provide written permission for me …
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