"Daybreak Face Sheet Template"

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DAYBREAK FACE SHEET
PATIENT INFORMATION:
Name: ___________________________________________________ Sex: M / F Age: _____ Date of Birth: _____/_____/_____
Patient phone # (if applicable): ________________________ Patient email address: _______________________________________
Address: ___________________________________________________________________________________________________
Street
City
State
Zip
School Patient is Currently Attending: ______________________________________________________ Grade: _______________
Who Referred You Here? : _____________________________________________________________________________________
PARENT/GUARDIAN INFORMATION:
Name(s): ___________________________________________________________ Best contact phone #: _____________________
Parent 1 Email: _____________________________________ Parent 2 Email: __________________________________________
Address, if different from above: ________________________________________________________________________________
PRIMARY INSURANCE INFORMATION:
Insurance Co.: _______________________________________________________________________________________________
Insurance Co. Address: ________________________________________________________________________________________
Insurance Co. Phone #: _____________________________________
Name of Insured: __________________________________________ Relationship to patient: ______________________________
Insured’s Address: __________________________________
Employer: _______________________________________________
Insured’s SSN: ________-________-_________ Policy#: ___________________________________ Group#: _________________
SECONDARY INSURANCE INFORMATION:
Insurance Co.: _______________________________________________________________________________________________
Insurance Co. Address: ________________________________________________________________________________________
Insurance Co. Phone #: _____________________________________
Name of Insured: __________________________________________ Relationship to patient: ______________________________
Employer: ________________________________________________ Insured’s Address: __________________________________
Insured’s SSN: ________-________-_________ Policy#: __________________________________ Group#: _________________
MEDICAL INFORMATION:
Allergies: ___________________________________________________________________________________________________
Current Medications, Dosages, and Prescribing MD: _________________________________________________________________
____________________________________________________________________________________________________________
Pharmacy Name and Phone#: ____________________________________________________________________________________
Emergency Contact Name and Phone#: ____________________________________________________________________________
I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED, REGARDLESS OF
INSURANCE COVERAGE OR OTHER THIRD PARTY LIABILITY.
________________________________________________
_____/_____/_____
SIGNATURE
DATE
DAYBREAK FACE SHEET
PATIENT INFORMATION:
Name: ___________________________________________________ Sex: M / F Age: _____ Date of Birth: _____/_____/_____
Patient phone # (if applicable): ________________________ Patient email address: _______________________________________
Address: ___________________________________________________________________________________________________
Street
City
State
Zip
School Patient is Currently Attending: ______________________________________________________ Grade: _______________
Who Referred You Here? : _____________________________________________________________________________________
PARENT/GUARDIAN INFORMATION:
Name(s): ___________________________________________________________ Best contact phone #: _____________________
Parent 1 Email: _____________________________________ Parent 2 Email: __________________________________________
Address, if different from above: ________________________________________________________________________________
PRIMARY INSURANCE INFORMATION:
Insurance Co.: _______________________________________________________________________________________________
Insurance Co. Address: ________________________________________________________________________________________
Insurance Co. Phone #: _____________________________________
Name of Insured: __________________________________________ Relationship to patient: ______________________________
Insured’s Address: __________________________________
Employer: _______________________________________________
Insured’s SSN: ________-________-_________ Policy#: ___________________________________ Group#: _________________
SECONDARY INSURANCE INFORMATION:
Insurance Co.: _______________________________________________________________________________________________
Insurance Co. Address: ________________________________________________________________________________________
Insurance Co. Phone #: _____________________________________
Name of Insured: __________________________________________ Relationship to patient: ______________________________
Employer: ________________________________________________ Insured’s Address: __________________________________
Insured’s SSN: ________-________-_________ Policy#: __________________________________ Group#: _________________
MEDICAL INFORMATION:
Allergies: ___________________________________________________________________________________________________
Current Medications, Dosages, and Prescribing MD: _________________________________________________________________
____________________________________________________________________________________________________________
Pharmacy Name and Phone#: ____________________________________________________________________________________
Emergency Contact Name and Phone#: ____________________________________________________________________________
I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED, REGARDLESS OF
INSURANCE COVERAGE OR OTHER THIRD PARTY LIABILITY.
________________________________________________
_____/_____/_____
SIGNATURE
DATE