Patient Information Form Please fill out the form below or download this form to print and fill out. You can e-mail the completed form to the Facility location you will be visiting: Beaumont@TriangleTherapeutics.com or PortArthur@TriangleTherapeutics.com First Name*Middle InitialLast Name*Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Social Security #*Date of Birth*Driver's License #*Email* Sex*MaleFemaleHow Did You Hear About Us?*Check all that apply Friend / Family Doctor Yellow Pages Social Media / Internet Community / Events Other Friend / Family Member's Name:Doctor's Name:If Community / Events, please list:If other, please list:EthnicityWhiteBlackAsianHispanicArabicAlaskanAmerican IndianOtherIf other, please specify ethnicity:Marital Status:MarriedSingleDivorcedOtherSpouse's NameEmergency Contact Name*Emergency Contact Phone*WORK / SCHOOL INFORMATIONStatusWorking full-time out of homePart-time out-of homeFull time from homePart-time from homeWorking w/ modification because of current injuryNot working because of current injuryHomemakerStudentRetiredUnemployedOccupation (if applicable)Employer’s NameEmployer’s PhoneEmployer’s AddressStudentYesNoIf yes, please list school:Consent I consent to the following at TTI (Triangle Therapeutics Inc.). Please check all of the below.* Treatment. I voluntary consent to outpatient services, assessment & treatments as ordered by my Physician. * I am responsible for my PERSONAL ITEMS & TTI is not responsible for any items that are lost, stolen or damaged. * I have received & understood the No Show & Cancellation Policy, HIPAA Privacy Notice, Insurance Verification or Financial Responsibility Form, Patient Guidelines & Responsibilities. * I grant permission to TTI to obtain information from health care providers, payor source or employer &/or school applies to my treatment. I also grant permission to TTI to release my medical information to healthcare providers and payor sources (insurance, third party, lawyer) for the purpose of continuing care, reimbursement or legal reasons. * I grant permission for TTI to take PHOTOGRAPHS/VIDEOS of myself during my stay which may be used for advertising, marketing & promotion. I certify that the above information are true and correct to the best of my knowledge.Patient Signature*Please type full name for a digital signature.Which location will you be visiting?*BeaumontPort Arthur*Thank you for filling out your patient information form. Page 1 of 4 forms, hit submit to continue to the next form.