Address:  2425 W. Broad St., Suite 2  Athens, GA 30606  Get Directions   Phone:  706-543-2584  Fax:  706-354-0702  Email Us!		Patient Registration First Name: Middle Name: Last Name: Address City State Zip Home Phone Cell Phone Work Phone Fax Email Address Social Security # Birth Date Age Marital Status Single Married Divorced Occupation Employer Employer Address City State Zip Spouses Name Occupation Employer Nearest Relative Phone Relative Address City State Zip How did you hear about us? Purpose of appointment Date of symptoms or accident:    Days of work missed?    Has a physician treated you for any health condition in the past year? No Yes If yes, describe:   What medications or drugs are you taking? What is the name of your family doctor? Would you like us to send a copy of your exam results to your doctor? No Yes Please check any and all insurance that my be applicable:  Major Medical   Medicaid   Auto Accident   Other Name of Primary Insurance: Name of Member/Subscriber ID: Group Number: Customer Service Phone Number: Name of Secondary Insurance: