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Silver Sage Center Patient Information Sheet
Silver Sage Center for Family Medicine is currently accepting new patients. To set up an appointment contact us at 775-853-9394 or fill out the SSC forms to pre-register for an appointment.
In the event of a serious or life-threatening emergency, call 911 or go directly to a Medical Center Emergency Room located nearest you.If you need the Police, an Ambulance or the Fire Department for an Emergency, call 911.
Patient Information
Name
First
Last
Home Phone
Cell Phone
Work Phone
Email
Patient Social Security #
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Separated
Physical Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing address is different than physical address.
Yes
No
Mailing Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you require a language translator?
Yes
No
What language?
Are you visually impaired?
Yes
No
Are you hearing impaired and require a sign language translator?
Yes
No
If not, can we communicate via paper?
Yes
No
Emergency Contact
Name
First
Last
Phone
Relationship
Patient or Parent Employment Information
Employer
Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name of Employee
First
Last
Occupation
Insured Social Security #
Work Phone
Insurance Information
Name of Subscriber
First
Last
Realtionship to Patient
Birthdate of Subscriber
Date Format: MM slash DD slash YYYY
Social Security #
Name of Employer
Work Phone
Insurance Company
Policy Number
Group Number
Secondary Insurance
Subscriber Name
First
Last
Birthdate of Subscriber
Date Format: MM slash DD slash YYYY
Relationship to Patient
Employer
*
I understand that co-payments are due at time of visit. I authorize payment of medical benefits from my insurance company to Silver Sage Center for Family Medicine. I also authorize the release of any medical information necessary to process any medical claim. I realize that I am responsible for any balance my insurance company does not cover/pay. I acknowledge receipt of the privacy policies and practices notice.
Disclosure
We can not release ANY information to any one else but the patient without written permission from the patients.
Is there a friend or family member whom we may disclose your medical information?
First
Last
What is there relationship to you?
Signature
We do not discriminate against anyone regardless of color, race or creed or physical ability.
What is the best means to contact you?
Home
Cell
Work
Email
Mail
Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Signature
*
By checking this box, I am agreeing that this information is being submitted digitally via the web, and will serve as an acceptance in place for my signature.
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