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FAMILY MEDICAL CENTER of LaGRANGE - PATIENT DATA INFORMATION

Today’s Date: ____________________________, 20______
PATIENT INFORMATION

Your Full Name: _____________________________________________                            Last Name, Suffix		______________________________________________  ____________ First Name                                                                                   M.I.
Home Address: ______________________________________________		Home Phone: (_______) _______________________________________                           Area Code and Number
______________________________________________                          City, State, Zip Code
Date of Birth: ________/__________/_________		Marital Status:     S     M     W     D
Social Security Number: ____________ - ________ - ____________		Referred by: ________________________________________________
Employer: __________________________________________________		Work Phone: (_______) _______________________________________                           Area Code and Number
Address: ___________________________________________________		Cell Phone: (_______) _______________________________________                           Area Code and Number
___________________________________________________                  City, State, Zip Code		Occupation: _________________________________________________
Emergency Information
Contact Name:		Relationship:
Address: ___________________________________________________		Home Phone: (_______) _______________________________________                           Area Code and Number
___________________________________________________                  City, State, Zip Code		Work Phone: (_______) _______________________________________                           Area Code and Number
INSURANCE HOLDER (Responsible party; parent, guardian for children under 18)
Your Full Name: _____________________________________________                            Last Name, Suffix		______________________________________________  ____________ First Name                                                                                   M.I.
Home Address: ______________________________________________		Home Phone: (_______) _______________________________________                           Area Code and Number
______________________________________________                          City, State, Zip Code
Patient's Date of Birth: __________/__________/__________
Relationship to Patient:           ___ Spouse ___ Parent or Guardian ___ Child            ___ Other (please specify)                                          ______________________________________________		Social Security Number: ____________ - ________ - ____________ Occupation: _________________________________________________
Employer Name: _____________________________________________		Phone Number:  (_______) _____________________________________                           Area Code and Number

I hereby assign, transfer, and set over to Family Medical Center of La Grange all of my rights, title, and interest of my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all changes whether or not they are covered by my insurance.

Family Medical Center of La Grange, Ltd.
5201 S. Willow Springs Road Suite 300
La Grange, Illinois 60525
(708) 482-8088