Demographics Sheet

2660 10th Ave. South

POB 1, Suite 301

Birmingham, Al 35205

Phone: 205-930-2369

Fax: 205-930-2715



Driver’s License  

Date of Birth  

Full Name                                                            Social Security Number

Address                                                               City                                          State                           Zip Code

Home Phone                    Cell Phone                        E-mail address

Where Employed                                   Work Phone

Primary Insurance                           Policy or ID #            Group #                      Policy Holder

Secondary Insurance                      Policy or ID #             Group #                     Policy Holder

Marital Status           Spouse Name                                       Spouse Date of Birth

Spouse Employer Name                                     Telephone #

Name and Number of person to notify in case of Emergency (other than spouse)

Referred by Whom?

Please list any medications you are currently taking

Please list any known allergies

In carrying out my treatment, it might be necessary to FAX my records to the hospital or to a doctor’s office. By signing below I am authorizing the release of my medical records in this fashion.

It is the patient’s responsibility to notify this office of any insurance changes.

I understand that I am responsible for any and all charges incurred by me and that I agree to pay any collection costs incurred including a reasonable attorney’s fey.



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Document name: Demographics Sheet
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January 22, 2021 9:54 am CDTDemographics Sheet Uploaded by Dylan Richardson - IP