Established Patient Health History & Demographics Online Form

Please fill out the information below for the PATIENT who has an appointment with GTOC.  If your appointment is within 2 business days from the current date, please do not submit online forms.  We may not be able to process the information in time for your appointment.  Instead, please print out/fill out the New Patient Info forms and bring them with you on the day of your appointment.  Please plan to arrive 15 minutes early for your appointment and bring your newest insurance cards and photo ID.

If you do not wish to submit your form online you may download, print and fill out your forms and bring them with you to your appointment or fax them to 231-947-8864.

* required

  4. (mm/dd/yyyy)

  5. Address *

  6. (xxx-xx-xxxx)
    THIS FIELD IS OPTIONAL

  8. (Example: David Jones, husband)

  9. (xxx) xxx-xxxx

  10. (xxx) xxx-xxxx

  12. (Name/Street/City)

  14. (Please list all medications with strength of med and dosage instructions, example: Aspirin 325 mg 2 times a day)

  15. (AREDS, Macular Degeneration)

  17. (Please list all, Name, Strength, Dosage)

  22. (Please list all known allergies or indicate "NONE")

  23.  (Please list procedure and year date)

  36. (Please proceed with year date)

  37. (check all that apply)

  38. (Dr. name, Clinic name, City)

  39. (Dr. name, Clinic Name, City)

  40. (Dr. name, Clinic Name, City)

  43. (chew/snuff/dipping)

  46. (optional)

  47. (Please include: Carrier Name, Last 4 digits of Subscriber’s SSN#, Subscriber Full Name and Subscriber DOB)

  48. (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

  49. (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

  50. (Please include: Carrier Name, Contract/ID#, Subscriber Full Name, Subscriber DOB)

  54. To the best of my knowledge the above information is accurate at the time of submission. *