Demographics Form

Patient Demographic Form

Personal Information

Legal Name *

Preferred Name *

Date of Birth *

SSN *

Preferred Pharmacy

Primary Care Doctor

Race *

White
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Other

If other, please specify your race *

Ethnicity *

Not Hispanic, Latino, or Spanish Origin
Hispanic, Latino, or Spanish Origin

Gender *

Male
Female
Undifferentiated

Birth Sex *

Male
Female
Undifferentiated

Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Parent/Legal Guardian Information (If under 18)

Guardian #1 Full Name

Guardian Date of Birth

Guardian SSN

Guardian #1 Relation

Phone Number

Guardian #2 Full Name

Guardian #2 Date of Birth

Guardian #2 SSN

Guardian #2 Relation

Phone Number

Emergency Contact other than Parent/Guardian

Emergency Contact Full Name

Relation

Phone Number

Do you want access to the online patient portal? If yes, please provide your email below.

Please provide FRONT & BACK of Insurance Cards AND Photo ID

By entering my full name here, I hereby acknowledge all the information submitted is accurate to the best of my availability. I give Pediatric Gastroenterology of Idaho the right to collect this information in preparation for my next visit. *

Prove that you're human. *