SUSAN D. GIFFORD, Ph.D. P.C. & ASSOCIATES

3508 Hwy 121 Bedford, TX  76021 817.858.6745 Fax 866.341.1114 www.DrGifford.com

 

                                         INFORMATION SHEET

 

Patient Name:   Age:       Birthdate: 

Parent or Guardian:

Address:  City:  State:   Zip:

Phone (Home):      (Office):       (Cell): 

Driver's License#:            Spouse's License#:   

 

Person to be billed (if different from patient): 

Address:  City:  State:   Zip:

Phone (Home):      (Office):       (Cell): 

 

Person to be notified in case of emergency: 

Address:  City: , State:   Zip:

Phone (Home):      (Office):       (Cell): 

 

Family physician:         Phone:

Who referred you?        Relation to you: 

 

We routinely send e-mail reminders two days prior to your
scheduled appointment if you wish to furnish your e-mail address:

Patients are responsible for full payment for any missed appointments or appointments canceled within 24 hours prior to the scheduled appointment. A 24 hour advance notice must be given for any change in a scheduled appointment.

 

If you have applicable medical insurance and want us to file insurance for you, please complete the following:

 

Primary Insurance Company:       Phone Number: 

ID # on Insurance Card:       Policy or Group #: 

Insured's Name:       Insured's Date of Birth: 

Insured's Employer: