NEW PATIENT FORM

Thank you for selecting our healthcare team! We strive to provide you with the best possible healthcare. To help us meet your healthcare needs, please fill out these forms completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help.

CONFIDENTIAL PATIENT INFORMATION (PLEASE PRINT)

DATE:______________

NAME ______________________________ DOB ____________ HOME PHONE______________________

FIRST MI LAST (DATE OF BIRTH)

ADDRESS_________________________CITY__________________________ STATE__________ ZIP____________

SSN #________________________________WHO IS RESPONSIBLE FOR THE BILL? __________________
(SOCIAL SECURITY NUMBER)

PATIENT’S EMPLOYER: ________________________ WORK PHONE# ______________________

CIRCLE THE APPROPRIATE: - MINOR - SINGLE - MARRIED - WIDOWED - DIVORCED -

CIRCLE THE APPROPRIATE: - FEMALE - MALE -

Who referred you to our office so that we may thank them?______________________________________________________

Please bring your insurance card to the front desk, if you would like us to submit your claim. As a courtesy, we will be happy to file your insurance for you at no charge; however, payment is required at the time of service.

FINANCIAL ARRANGEMENTS (Payment in full is expected at each appointment)

HEALTH INSURANCE COMPANY_______________________________________

For your convenience, we offer the following methods of payment. Please check the option which you prefer.
 

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or other health practitioners.

I authorize and request my insurance company to pay directly to the doctor or thedoctor’s group insurance benefits otherwise payable to me.

I also understand that I am financially responsible for all my or my dependents charges whether or not covered by insurance.

X___________________________________________________________