Choice for State of the Art Toxicology
Patient CareHome PageOffice FormsRespiratoryNew Patient Demographic Data Sheet for all new patients

Demographic Data Sheet.


Please fill out the following information:



Name:________________________________  Date:__________





Social Security Number:_____________________ Birth date:________________________  


Home telephone number:____________________  Present Employer:_________________         


Work telephone number:____________________   Gender: Male_____            Female_____


Marital Status:              Single_____   Married_____   Widowed_____   Divorced/Separated_____


Race:            White_____ African American_____ Asian____ Latino___ Indian___Other__


Medication Allergies:______________________________


Who do we contact in case of an emergency?


Name:__________________________________ Phone number:________________________


For those seen under Workers’ Comp, please sign the Medical Release below


I hereby authorize the release of all medical records, including but not limited to psychological, psychiatric, alcohol and drug related and all other pertinent medical information relevant to my complaint of injury related to my Workers’ Comp claim.  Additionally, I authorize my employer and its Workers’ Comp carrier and their representatives and agents to communicate directly both orally and in writing with all treating physicians or medical providers of any kind regarding all facts and opinions relevant to my Workers’ Comp claim until my claim has ended.  I understand that pursuant to SC. Code Ann.  42-15-80 that no fact communicated to or otherwise learned by any physician or surgeon who may have attended or examined me, or who may have been present at any examination, is privileged. 


________________________________            ________________________________

Patient Care | Home Page | Office Forms | Respiratory Clearance Form | New Patient Form