patient demographics with logo

Patient Demographics/Information Sheet
Name

Patient First NameMiddle InitialLast Name
DOB
Sex MF circle SSN
Marital Status S/M/D/W (circle)
Drivers License State
Email For Patient Portal
example@example.com
Address

Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Home
Work
Cell
Patient EmployerAddress
Phone/Ext
Primary Insurance Carrier
Policy Number
Group Number
Policy Holder Name
DOB
SSN
Secondary Insurance Carrier
Policy Number
Group Number
Policy Holder Name
DOB
SSN
If there is a Tertiary Insurance please list here
Is there another relative with whom we can discuss your care? (son daughter spouse other) NamePhone
Name
I/We hereby state that the above information is true and correct to the best of my/our knowledge. I/We authorize the above named practice to release any information acquired in the course of my treatment to my insurance company, employer, Physicians, institutions or third party payers as required for certain claims filed. My/Our signature also signifies my/our consent to medical treatment deemed necessary by the physician and/or the office staff acting under the physician's direction. There are Nurse Practitioners that work with Dr. Lano who have extensive training and experience in the evaluation & treatment of Ear, Nose and Throat patients. They have experience in caring for surgical patients. They are supervised by Dr. Lano and may be involved in your care.
Signature of PatientParentGuardian

Clear
Printed Name
Date

MonthDayYear
Date
Signature of PatientParentGuardian

Clear
I/We authorize direct payment to be made to the above named practice for any and all medical and surgical services rendered. I understand if any services or charges are not covered by my insurance carrier or my eligibility cannot be verified, I am responsible for charges incurred.
Printed Name
Date

MonthDayYear
Date
42 Gruene Park Drive830-629-5830 / FAX 830-629-3647 New Braunfels, TX 78130
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