PATIENT INFORMATION

PATIENT INFORMATION

** Any changes to your phone number, address, or insurance should be reported to the front desk. Acceptable Forms of Payment: DEBIT OR CREDIT CARD ONLY. NO CASH OR CHECK**
Patient Full Name *
Patient DOB *
Patient SSN
Today's Date *

Month Day Year
Date
Legal Orders
Is this patient involved in any legal documentation such as but not limited to: Divorce Decree, Custody Orders, Adoption Documentation, Power of Attorney, etc *

Yes No
(If yes, please indicate the nature of the situation and provide a copy to the Front Office for our records.)
Legal Guardian(s)/Parent(s)
Name and DOB *
Relationship to Patient *
Contact Number *
Name and DOB
Relationship to Patient
Contact Number
Patient Information
Gender *

Female Male Other
Language *

English Spanish Other
Is an interpreter needed

Yes No
Hearing or Visual Impairment

Yes No
If yes, please indicate the nature of impairment
Religious Preference *

Christian Catholic Jewish Islam Atheist Other
Marital Status *

Single Married Divorced Widowed Other
Employment Status *

Employed Full Time Student Part Time Student Unemployed Other
Employer Name (If applicable)
School Name (If applicable)
Patients' Residential Address
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number: Cell Phone *
Home Phone
Email *
example@example.com
Preferred Method for Reminders:

Text Email Phone call
Emergency Contact

Leave Blank if None Available
Name
DOB
Contact Number
Please enter a valid phone number.
Relationship to Client
Let us know who we can thank for referring you to our center
Select how you were referred

Google/Internet TV/Commercial Friend/Relative Doctor's Office Other
If you selected doctor's office (Please Name)
The fee for missed appointments and cancelled appointments with less than a 24 hour notice will be $60. The fee for missed appointments for testing will be $100.
Insurance Information

In order for our center to bill your insurance, this form will need to be completed in full in addition to providing the Front Office with a copy of your insurance card.
Primary Insurance Carrier Name *
Member ID *
Group ID *
Are you (the patient) the Primary Insured to this policy: *
Primary Insured Name and DOB *
Primary Insured Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number *
Please enter a valid phone number.
If any additional insurance, please note:
Secondary Insurance Carrier Name
Member ID
Group ID
Are you (the patient) the Primary Insured to this policy:
Primary Insured Name and DOB
Primary Insured Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number
Please enter a valid phone number.
Patient Care Form: Coordination of Services

The purpose of this section is to coordinate with your primary care physician to ensure we are able to provide the most effective standard of care.
Primary Care Physician (PCP) Name:
PCP Office Name
Office Number
Please enter a valid phone number.
Fax Number
Office Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient, please check one

I agree to release information to my physician listed above I do not agree to release this information to my physician listed above. I do not have a primary physician.
This consent shall expire one (1) year from the date of signature. I understand I may revoke my consent in writing at any time except to the extent that action has already been taken in reliance on it.
Patient or Legal Guardian Signature

Clear
Date

Month Day Year
Date
Should be Empty:

PATIENT INFORMATION

Legal Orders

Legal Guardian(s)/Parent(s)

Patient Information

Patients' Residential Address

Emergency Contact

Let us know who we can thank for referring you to our center

Insurance Information

If any additional insurance, please note:

Patient Care Form: Coordination of Services