PATIENT REGISTRATION FORM           Date: ______________            

 

Last Name___________________________________ First Name_____________________________ Middle Initial ____

 

Prefer to be called_______________ Sex:  M    F    (Please Circle)  Married   Single   Divorced   Widowed  (Please Circle)

 

Date of Birth_______/_______/_______ Age_______ SSN_________ Who Referred You? ______________________

                      Month      Day       Year

 

Address_________________________________ City_________________________ State__________ Zip__________

 

Employer_________________________________________________________________________________________

               Name                                                                       Address                                                        Phone

 

Home Phone (     )__________________ Work Phone (     )________________Cellular Phone (     )_________________

 

Person to contact in case of emergency:_________________________________________________________________

                                                                   Name                                                        Address                                Phone

 

Spouse:___________________ Spouse’s Date of Birth:__________ Spouse’s Employer__________________________

 

Has any other member of your family been treated in this office?                         YES         NO

 

If yes…..Name_________________________________________  Age________ Relationship_____________________

 

              Name__________________________________________ Age________ Relationship____________________

 

Billing Information

Where should your statements of your account be sent if different from above?

 

_________________________________________________________________________________________________

Name                                                     Address                                             City                                    State               Zip

 

Insurance Information

Name of Insurance Company_______________________________ Address___________________________________

 

Name of Insured_______________________________________ Relationship to Insured_________________________

 

Insured Date of Birth______________________ Insured Employer ___________________________________________

 

ID#_____________________________________________ Group ID#________________________________________

 

Please present insurance cards to the receptionist so copies may be made.

 

In order to establish optimal relations with our patients and avoid misunderstanding regarding our payment

policies, our staff is trained to inform you of the financial policies of this office.  PAYMENT IS EXPECTED

FROM YOU, AT THE TIME OF SERVICE FOR “YOUR PART” OF THE CHARGES.  WE ACCEPT VISA,

MASTERCARD, DISCOVER AND AMERICAN EXPRESS FOR YOUR CONVENIENCE.  If you do not have

insurance, payment in full is expected at time of service unless payment arrangements have been made.

Balances on all accounts over 90 days are subject to interest charges at the rate of 1.5% per month.  Your

signature below indicates that you understand and accept this policy.  Further, your signature authorizes the

Doctor to release such medical information necessary to process your insurance claims (if any).  You herein

authorize payment of medical benefits to the Doctor when an assigned claim is filed.

 

___________________________________________________________                  _____________________________

                           Signature of Patient or Legal Guardian                                                                         Date

 

Should the account fall into arrears greater than 60 days, I authorize any

unpaid balance to be charged to my major credit card, as listed below.                                                                                                                                                                                                                                                   

Circle One:  Visa        Mastercard         Discover        American Express                                                                                                    

                                                                                                                                                                                                                         

____________________________________        ___________________

Card #                                                                                     Expiration Date

____________________________________   

Name as it appears on Card   

 

____________________________________        ___________________

Signature                                                                                Date