UPDATE YOUR PATIENT INFO

Patient Name

Age

Date of Birth

Date

Social Security #

Marital Status

SDWM

Street Address

City

State

Zip Code

Home Phone

Work Phone

Cell

What form of communication may we use to contact you?

Employer

Position

Email Address

example@example.com

Employer Phone

Employer Address

Is the Patient a Minor?

YN

If so, name of responsible party

Responsible party's Address

Phone

Relationship to patient

Person(s) we may contact in case of an emergency:

Person 1 Name

Relationship to patient

Phone #1

Phone #2

Phone #1 Type

HomeCellWork

Phone #2 Type

HomeCellWork

Person 2 Name

Relationship to patient

Phone #1

Phone #2

Phone #1 Type

HomeCellWork

Phone #2 Type

HomeCellWork

Patient or Responsible Party Signature

Signature

Date

Who may we thank for referring you to us?

By Signing, I understand that Lang & Dr. Derek H. Lang have "opted out" of Medicare, effective November 1, 2004. I also understand that I will be responsible for payment of all charges incurred after the above date, including any laboratory work up (blood studies I further understand that these charges will not be sent to Medicare (no reimbursement) nor to my secondary insurance company (no reimbursement) because Medicare will not pay for any of my services.

I also agree to be responsible for all expenses incurred

Patient Name

Medicare #

Signature

Date

UPDATE YOUR PATIENT INFO

Medicare Eligible Patients