$lastname = $_REQUEST["lastname"]; $firstname = $_REQUEST["firstname"]; $middlename = $_REQUEST["firstname"]; $street = $_REQUEST["street"]; $city = $_REQUEST["city"]; $state = $_REQUEST["state"]; $zip = $_REQUEST["zip"]; $relation = $_REQUEST["relation"]; $harea = $_REQUEST["harea"]; $hnumber = $_REQUEST["hnumber"]; $carea = $_REQUEST["carea"]; $cnumber = $_REQUEST["cnumber"]; $month = $_REQUEST["month"]; $day = $_REQUEST["day"]; $year = $_REQUEST["year"]; $age = $_REQUEST["age"]; $ss = $_REQUEST["ss"]; $employment = $_REQUEST["employment"]; $barea = $_REQUEST["barea"]; $bnumber = $_REQUEST["bnumber"]; $econtact = $_REQUEST["econtact"]; $erelation = $_REQUEST["erelation"]; $earea = $_REQUEST["earea"]; $enumber = $_REQUEST["enumber"]; $fdoc = $_REQUEST["fdoc"]; $refferedby = $_REQUEST["refferedby"]; $slastname = $_REQUEST["slastname"]; $sfirstname = $_REQUEST["sfirstname"]; $smiddlename = $_REQUEST["$smiddlename"]; $smonth = $_REQUEST["smonth"]; $sday = $_REQUEST["sday"]; $syear = $_REQUEST["syear"]; $sss = $_REQUEST["$sss"]; $semployment = $_REQUEST["semployment"]; $sbarea = $_REQUEST["sbarea"]; $sbnumber = $_REQUEST["sbnumber"]; $pico = $_REQUEST["pico"]; $piid = $_REQUEST["piid"]; $pigroup = $_REQUEST["pigroup"]; $psubscribername = $_REQUEST["psubscribername"]; $prelationtosubscriber = $_REQUEST["prelationtosubscriber"]; $psubmonth = $_REQUEST["psubmonth"]; $psubday = $_REQUEST["psubday"]; $psubyear = $_REQUEST["psubyear"]; $sico = $_REQUEST["sico"]; $siid = $_REQUEST["siid"]; $sigroup = $_REQUEST["sigroup"]; $ssubscribername = $_REQUEST["ssubscribername"]; $srelationtosubscriber = $_REQUEST["$srelationtosubscriber"]; $ssubmonth = $_REQUEST["ssubmonth"]; $ssubday = $_REQUEST["ssubday"]; $ssubyear = $_REQUEST["ssubyear"];

1. Name of Client:

Last:
" . $lastname . "> First:
" . $firstname . "> Middle
" . $middlename . ">

2. Home Address:

Street:
" . $street . "

City:
" . $city . " State:
" . $state . " Zip:
" . $zip . "

3. Please Check One

" . $relation . "

4. Telephone: Home: " . $harea . " - " . $hnumber . " Cell: " . $carea . " - " . $cnumber . "

5. Date of Birth: " . $month . " / " . $day . " / " . $year . " Age: " . $age . "

Social Security #: " . $ss . "

6. Employment if Applicable: " . $employment . "

Business Phone: " . $barea . " - " . $bnumber . "

7. Emergency Contact:

Name:
" . $econtact . "

Relation to Patient:
" . $erelation . " Telephone #:
" . $earea . " - " . $enumber . "

8. Family Medical Doctor: " . $fdoc . "

Referred By:
" . $refferedby . "

Spouse Information

9. Name:

Last:
" . $slastname . " First:
" . $sfirstname . " Middle
" . $smiddlename . "

10. Date of Birth: " . $smonth . " / " . $sday . " / " . $syear . " Social Security #:
" . $sss . "

11. Employment: " . $semployment . "

Business Telephone: " . $sbarea . " - " . $sbnumber . "

Insurance Information

12. Primary Insurance Co: " . $pico . "

ID#:
" . $piid . "

Group:
" . $pigroup . "

Name of Subscriber:
" . $psubscribername . "

Relationship to Subscriber:
" . $prelationtosubscriber . "

Subscribers Date of Birth (if other than patient): " . $psubmonth . " / " . $psubday . " / " . $psubyear . "

13. Secondary Insurance Co: " . $sico . "

ID#:
" . $siid . "

Group:
" . $sigroup . "

Name of Subscriber:
" . $ssubscribername . "

Relationship to Subscriber:
" . $srelationtosubscriber . "

Subscribers Date of Birth (if other than patient): " . $ssubmonth . " / " . $ssubday . " / " . $ssubyear . "