Demographic Sheet

This form must be completed in full

Cary Surgical Specialists, PC

Patient Last Name		Patient First Name		Middle Initial	Male______ Female_____
Date of Birth	Patient’s Social Security Number		Home Number	Work Number	Cell Number
Mailing Address City State Zip
Home Address If Different
Referring Physician (Dr’s Name) Address Phone Number
Primary Care Physician (Dr’s Name) Address Phone Number
Patient’s Employer Phone Number
Spouse’s Name Spouse’s Employer Spouse’s work Number
Emergency Contact Relationship Phone Number
Guarantor (Person responsible for bill) Date of Birth Social Security Number Address of Guarantor
Primary Insurance Name of Policy Holder SS# of Policy Holder Date of Birth of Policy Holder ID# on Policy Policy Group # Policy Holder Employer
Secondary Insurance Name of Policy Holder SS# of Policy Holder Date of Birth of Policy Holder ID# on Policy Policy Group # Policy Holder Employer
Workman’s Compensation? (Circle One) Yes No

Full payment is due at the time of service. I agree to be responsible for my expenses. I authorize my insurance company,
attorney or any other parties to pay Cary Surgical Specialists, PC. directly and provide any information regarding payment
of my medical charges. I accept responsibility for any balance due and any items not covered by my insurance company.
I authorize the physician to administer medical care as is necessary.

Signature:____________________________________________________________ Date ____________________