Demographic Data Sheet (print and fill out)

Please fill out the following information:

Name:________________________________ Date:__________

Address:______________________________

_____________________________________

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.

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