ALLERGY-ASTHMA-RHEUMATOLOGY ASSOCIATES, P.C.
1200 East Genesee Street, Suite 103, Syracuse, NY 13210
Phone: 315-478-2339 FAX:
315-478-0439
MICHAEL G. SHEEHAN, M.D.
N. ANDREI POPESCU, M.D.
HARCHARAN SINGH, M.D.
Allergy/Immunology
Allergy/Immunology Allergy/Immunology
Certified
by the American Board of Allergy and Immunology
PATIENT
INFORMATION SHEET
Name (first)_________________(M)___(last)_______________________________________
Date of birth:_____________Age:____________Sex: M/F
Marital status S/M/W/D
Address______________________________________________________________________
City, State,
Zip________________________________________________________________
Phone #____________________________________Social
Security #____________________
Work
#______________________Employer________________________________________
Employer’s
address:___________________________________________________________
Referring
physician:___________________________________________________________
RESPONSIBLE
PARTY OR SPOUSE INFORMATION
Name_______________________________Relationship to
patient_____________________
Address______________________________________________________________________
City, State,
Zip________________________________________________________________
Phone #______________________Social Security #__________________________________
Work
#__________________________Employer_____________________________________
Employer’s
address_____________________________________________________________
INSURANCE
INFORMATION
PRIMARY SECONDARY
Ins. Co. Name__________________________ Ins. Co. Name________________________
Ins. Co. address_________________________ Ins. Co.
address_______________________
ID#________________Group #____________ ID#__________________Group #_________
Insured’s name_________________________ Insured’s
name_________________________
Insured’s SS #__________________________ Insured’s
SS#___________________________
Insured’s employer______________________ Insured’s employer_______________________
Relationship to patient___________________ Relationship to
patient____________________
Birth date of policyholder_________________ Birth date of
policyholder__________________
I hereby authorize the treating physician to release any
information acquired in the course of examination
or treatment to
other physicians I may see and allow a photocopy of my signature to be used.
_________________________________________ ____________________________
Signed by Patient or Parent if Minor Date