Patient Information

Your Family Doctor:
Family Doctor:
Doctor's Phone #:
Your Information:
Full Name:
Street Address:
City, State & Zip:
Home Phone:
Work Phone:
Cell Phone:
Date of Birth:
Social Security Number:
Marital Status:
Employer/School Information:
Name:
Street Address:
City, State & Zip:
IN CASE OF EMERGENCY/GUARDIAN (if patient is a minor):
Name:
Relationship, Home Phone, Other Phone:
Insurance Information:
	(THIS INFORMATION IS ON YOUR INSURANCE CARD)
PRIMARY Name/Type of Policy:
SECONDARY Name/Type of Policy:
	If you have other insurance, please write the name of the company and type of policy here:
SPACING SPACING Policy Holder Name, Relationship:	** IF THIS IS NOT YOUR POLICY, PLEASE SUPPLY US WITH THE SUBSCRIBER INFORMATION BELOW SO THAT THE INSURANCE CAN BE BILLED CORRECTLY**
Policy Holder Date of Birth, Social Security:
Street Address, City, State & Zip Code:
Employer, Employer's Phone Number:
Employer's Address, City, State & Zip Code:
SPACING SPACING	** I UNDERSTAND THAT THERE IS A $10.00 (TEN DOLLAR) FEE FOR CANCELLATIONS WITHIN 24 HOURS OF APPOINTMENT AND FOR NO SHOWS. ** I ALSO UNDERSTAND THAT IT IS MY RESPONSIBILITY TO BRING MY CO-PAY & PAY ON OUTSTANDING BALANCES & BRING MY REFERRAL, IF NEEDED, FOR EACH VISIT. I VERIFY THAT THIS INFORMATION IS CORRECT AND THAT BY ELECTRONICALLY SUBMITTING THIS INFORMATION IS MY AGREEMENT TO ABIDE BY THE TERMS DESCRIBED ABOVE.

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