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Demographic Data
Sheet.
Please fill out the following
information:
Name:________________________________
Date:__________
Address:______________________________
_____________________________________
Social Security
Number:_____________________ Birth
date:________________________
Home telephone
number:____________________
Present Employer:_________________
Work telephone
number:____________________ Gender: Male_____
Female_____
Marital Status:
Single_____
Married_____
Widowed_____
Divorced/Separated_____
Race:
White_____ African American_____ Asian____ Latino___
Indian___Other__
Medication
Allergies:______________________________
Who do we contact in case of an
emergency?
Name:__________________________________
Phone number:________________________
For those seen under Workers’
Comp, please sign the Medical Release below
I hereby authorize the release of
all medical records, including but not limited to psychological,
psychiatric, alcohol and drug related and all other pertinent
medical information relevant to my complaint of injury related to my
Workers’ Comp claim.
Additionally, I authorize my employer and its Workers’ Comp
carrier and their representatives and agents to communicate directly
both orally and in writing with all treating physicians or medical
providers of any kind regarding all facts and opinions relevant to
my Workers’ Comp claim until my claim has ended. I understand that pursuant
to SC. Code Ann.
42-15-80 that no fact communicated to or otherwise learned by
any physician or surgeon who may have attended or examined me, or
who may have been present at any examination, is privileged.
________________________________
________________________________
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