PATIENT INFORMATION FORM

PATIENT INFORMATION
PATIENT’S LEGAL NAME:

First NameMiddle /Initial/Last Name
PREFERRED NAME
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
RESPONSIBLE PERSON NAME:

First NameLast Name
SOCIAL SECURITY NUMBER
RELATION TO PATIENT
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREFERRED PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL ADDRESS
example@example.com
How would you like to receive appointment reminders? Please check your choice:
INSURANCE INFORMATION
INSURED NAME:

First NameLast Name
SOCIAL SECURITY OR ID NUMBER
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
INSURANCE COMPANY NAME
PHONE
Please enter a valid phone number.Format: (000) 000-0000.
EMPLOYER NAME
* Please understand that your bill is your own personal responsibility. Insurance is designed to reimburse the policyholder for a loss and is a contract between the policyholder and the company. We do submit claims as a courtesy to all our patients; however, we are not obligated nor required to do so. We generally allow the insurance company up to 30 days to process all claims from the date of submission and longer should they require additional information. If the claim is not paid within a 90 day time period, we ask that you take care of the incurred charges and we reimburse you when the insurance has paid.
REFERRAL INFORMATION
WHO MAY WE THANK FOR REFERRING YOU?
IF THIS IS A PATIENT OR A DOCTOR, PLEASE PROVIDETHE PHONE NUMBER.
Please enter a valid phone number.Format: (000) 000-0000.
SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: