Randy L. Morton, M.D.
3209 North Fourth Street, Suite 300
Longview, Texas 75605 (903) 753-7205

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Patient Information
Name (first)___________________(middle)________________(last)_______________________
Address________________________________
City____________St__________Zip__________
Home Phone_________________Work Phone_____________ Cell Phone_________________
SS #________________________
DOB_____________Age_____Marital Status__________Spouse’s name____________________
Employer__________________________Occupation___________________________________
Employer Address__________________________
City___________St______Zip_____________
Emergency Contact Name and Number: __________________________________
How were you referred to us?__________________________________________________

Responsible Party (if other than patient)
Name (first)____________________(middle)________________(last)____________________
Address________________________________
City____________St__________Zip_________
Home Phone_________________Work Phone________________Cell Phone______________
SS #___________________ Employer__________________________Occupation___________________________________
Employer Address__________________________
City___________St______Zip_____________

Is this a result of a work injury?____Yes ____No  
Date Injured:__________ Claim #____________
Is this a result of an auto accident? ___Yes ___No
Date Injured:__________ Claim #____________

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government/medical benefits to the physician or party who provides services.

Patient’s or Responsible Party Signature: ________________________________Date__________