Bernard A. Rawlins, M.D. NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 2 months, please fill out just the first 2 pages and only items on other pages that have changed since your initial visit. Thank you for your cooperation. Date: Patient Name: Address: Date of Birth: Home Phone: ( ) Work: ( ) How were you referred to Dr. Rawlins: K Physician K Patient/ Friend K Insurance 0 Other: Referring Physician or Referral Source: - Address: City, State: Phone: ( ) Fax:( ) Do you want your medical records sent to this physician/ referral source? K Yes K No Primary Doctor: Address: City: Phone: ( ) Fax: ( ) Do you want your medical records sent to this physician? K Yes E No Are there any other physicians to whom you would like your medical records sent? (Please include name and address) EFTA00307789