Dr Queenan New Patient Questionnaire

Page 1 of 5     Demographic information   Please complete this questionnaire in its entirety in order to maximize our time together in your new patient visit. You will need to bring your insurance card to the visit for verification. Your answers to this questionnaire are confidential and will not be shared. Please try to provide as much detail as possible. Thank you for your time. I will contact you a verification that I have received your questionnaire. If you do not receive this e-mail within 2 business days after completing the questionnaire, please contact me.   1. Name* Please enter your full name as it appears on your insurance card         2. Your date of birth*   mm/dd/yyyy       3. Address* Please include city, state, zip code         4. Telephone number with area code*         5. Alternate telephone or cell phone number if applicable         6. E-mail address, if applicable Please see e-mail policy for appropriate use of e-mail in your medical care. If, after reading this policy, you would like to be able to communicate with your doctor via e-mail, please enter an e-mail address that you check regularly.         7. Emergency contact* Please include name, relationship, and phone number         8. Insurance Carrier* If you do not have health insurance, please indicate so.         9. Insurance Member ID number* Please include suffix if applicable (if you are covered under another person's insurance. Usually a number like -01 or 02...etc) If you do not have health insurance, please enter 000000         10. Insurance Guarantor's name (the name of the person the insurance policy is under)* If the guarantor is yourself, just indicate "self"         11. Insurance guarantor's date of birth*   mm/dd/yyyy       12. Do you have secondary insurance? If so please list the above information (Carrier, Member ID, Guarantor’s name and birthday) for your secondary insurance.         13. How did you hear about Queenan Family Medicine and Maternity Care?*