PEDRO M. ARGUELLO, M.D., F.A.C.P.
Diplomates of American Board of Internal Medicine and Gastroenterology
PATIENT INFORMATION
Thank you for choosing our office. In order to serve you properly we need the following information. Please Print

Patient Name (Last First Middle):
________________________________________Date: ____/____/____

Home Address: _____________________________________________
City_______________________,Texas Zip Code __________________

SS# _____-_____-_____ Male Female Birthday ____/_____/____

Phone: Home (______) _______________________________________
Cell (______) _________________Work (______)__________________

Marital Status:
Minor Single Married Divorced Separated Widowed

Patient’s Employer: _________________________________________________________
Work (______)__________________
Address:__________________________________________________
City___________________State_____________Zip Code___________

Spouse: __________________________________________________
Employer: _________________________________________________
Home (_____)______________________________________________
Cell (______)_________________Work (______)__________________

If the patient is a student, name school/college: _________________________________________________________ City___________________State_____________Zip Code___________

Person to contact in case of emergency other then spouse: _________________________________________________________

Referring Physician (if any): _________________________________________________________

RESPONSIBLE PARTY

If insurance is not in patient’s name please fill out the next line

Name of insured:
_________________________________________________________
Relationship to patient: _______________________________________

SS# _____-_____-_____ Male Female Birthday ____/_____/____

Address:__________________________________________________
City___________________State_____________Zip Code___________

Employer:_________________________________________________
Home (____)___________________Work (_____)_________________

INSURANCE INFORMATION

Primary Insurance:___________________________________________
ID#____________________________Group # ____________________

Employer: _________________________________________________
Work (_____)____________________

Secondary Insurance:_________________________________________
ID #_____________________________Group #___________________

AUTHORIZATION AND RELEASE

I authorize release of any information concerning my (or my child’s) health
care, advice and treatment provided for the purpose of evaluating and administering claims for the insurance benefits. I hereby authorize payment
of insurance benefits otherwise payable directly to Pedro M. Arguello,
M.D., P.A. I have reviewed and sign a copy of “The Health Insurance
Portability and Accountability Act of 1996“ (HIPAA)

_________________________________________________________
Signature of Patient or Guardian
Date_______/_______/________