PATIENT INFORMATION
Patient's Name   Birthdate  Age
Street Address  Female  Male
City  State Zip Code
Mailing Address (if different)
Home Phone  Work Phone  Cell Phone 
Patient's Employer  Address
Occupation  Social Security #  Driver's License #
Spouse's Name  Social Security #
Spouse's Employer  Occupation  Birthdate
Employer's Address  Work Phone

IF THE PATIENT IS A MINOR
Mother's Name  S.S.#  D.L. #
Mother's Employer  Occupation  Birthdate
Employer's Address  Work Phone
Father's Name  S.S. #  D.L.#
Father's Employer  Occupation  Birthdate
Employer's Address  Work Phone

INSURANCE INFORMATION
Primary Insurance Company  
Name of Subscriber
Address 
Insurance ID #  Medicare #
Secondary Insurance Company  
Name of Subscriber
Address  Insurance ID #

I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS AN INSURANCE CLAIM.  I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE PROVIDER OF SERVICES.

SIGNATURE  DATE

PAYMENT IS DUE AT TIME SERVICES ARE RENDERED.  IF YOU HAVE HEALTH INSURANCE IT SHOULD BE UNDERSTOOD THAT THIS IS AN AGREEMENT BETWEEN YOU AND AN INSURANCE COMPANY TO PAY CERTAIN AMOUNTS FOR MEDICAL CARE.  YOU ARE RESPONSIBLE FOR THE PAYMENT OF YOUR BILL REGARDLESS OF THE STATUS OF YOUR INSURANCE CLAIM.

By clicking below:
1. I agree to all the statements set out above
2. I warrant that I am the individual stated in this application and am authorized to request and approve these services
3. I agree to submit this registration to you electronically

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