PLEASE CLEARLY PRINT ALL PATIENT INFORMATION Today’s date:_____________
Last Name:__________________________________ First Name:___________________________________ MI:_______________
Gender: Male or Female Date of Birth:_____________ Age:___________ SS#:______________________________
Home Address:_____________________________________________________ Unit or Apt# ______________________________
City:___________________________________ State:___________________________ Zip Code:_________________
Home Phone #:__________-__________-____________ Ok to leave voicemail on home phone: YES or NO
Cell Phone #:__________-__________-______________ Ok to leave voicemail on cell phone: YES or NO
Confidential Email Address:__________________________________ Primary Care Physician:________________________
Pharmacy Used:_________________________________ Pharmacy Location:________________________________________
Emergency Contact:_____________________________ Relationship:_____________________ Phone:______________________
Race (PLEASE CIRCLE): Am Indian or Alaska Pacific, Asian, Black African Am, White, or Other Ethnicity: Hispanic or Latino or Other
Reason for visit:______________________________________________________________________________________________
INSURANCE INFORMATION
Name of Primary Insurance: ______________________ Insurance ID:____________________ Group:____________________
Policy Holder’s Name:___________________________ Relationship to Patient:_____________________________________
Policy Holder’s DOB:____________________________ Secondary Insurance:_______________________________________
GUARANTOR SECTION-COMPLETE IF PATIENT IS UNDER THE AGE OF 18
Guarantor Name (person financially responsible):________________________________ Relationship:_____________________
Address (if different from patient):______________________________________________ Unit or APT#:___________________
City:___________________________________ State:___________________________ Zip Code:_________________
__________________________________________________________________________________________________________
FINANCIAL POLICY (We accept credit or debit cards, cash. Personal checks are not accepted.)
I acknowledge full financial responsibility to any services received and I understand that the payment of charges incurred is due at the time of service. I also
understand that the charges not covered by insurance remain my responsibility and assign endurance benefits to this office. In the event that my account is
turned over to a collection agency, I agree to pay all late fees, costs of collection fees and/or Attorney’s fees and all
court costs, if any. Please indicate method of payment for today’s visit: Cash Credit Card Medicare Insurance
In order for us to service your account or to collect any amounts owed to us, we may contact you by telephone at any telephone number associated with
your account, including wireless telephone numbers, which may result in additional charges from your phone carrier. We may also contact you by
text/email. By initialing, I acknowledge that I have read this disclosure and agree that you may contact me as described above. X____________
I, the undersigned, consent to the care and treatment by the attending Physician, his/associates or assistants and acknowledge that no guarantees have
been made as to the effect of such treatment.
I have reviewed the Notice of Privacy as provided at registration and understand that I may request a copy of the policy at any time.
Signature: _________________________________________ Date:_____________________________________
