RETURNING Patient

Returning Patient

Commerical
Appointment*
Full Name:*

First NameLast Name
Birth Date: *

MonthDayYear
Date
Sex:*
Email:*
example@example.com
Marital Status:*
Other:
Address*

Street Address

Apartment / Building Number:

CityState / Province

Postal / Zip Code
City
State / Province:
Postal / Zip Code
*Primary / Cell Phone #:*
Please enter a valid phone number.
Home / Other Phone #:
Please enter a valid phone number
Work / Other Phone #:
Please enter a valid phone number.
Emergency Contact Name:
Emergency Contact Phone #:
Please enter a valid phone number.
How did you hear about us?
Other:
If applicable.
Insurance Company
Insurance Company:*
Sorry, you will not be able to make an appointment at our office, as we do not participate with your plan.
Policy Number:*
Group Number:
Specialist Copay Amount:*
Policy ID or SSN:
Claims Address PO Box Info (typically found on the back of your card):*

PO Box or Claims Street Address:

PO Box Info:

CityState / Province

Postal / Zip Code
Insurance Phone #:
Please enter a valid phone number.
Policy Holder
Patients Relationship to Policy Holder:*
Patient Name:*

First NameMiddle InitialLast Name
Birth Date: *

MonthDayYear
Date
Sex:*
*Primary / Cell Phone #:*
Please enter a valid phone number.
Home / Other Phone #:
Please enter a valid phone number.
Billing Address Is The Same As Patient's
Address:*

Street Address:

Apartment / Building Number:

CityState / Province

Postal / Zip Code
CANCELLATION POLICY:
At Alan Dayan MD, PC, FAAOS, we understand your time is important, as a result, we have reserved time for your visit with us. If you need to change the appointed time, we request at least 48 business hours (2 business days) notice. To maintain quality of care and keep from overbooking, our office requires such notice, otherwise, a $50 NO-SHOW FEE will apply. We understand that emergencies and illnesses may arise at the last minute, but please give us enough time so that other patients can use that reserved time. By signing below, you acknowledge you have listed all pertinent information, read and understand our Cancellation Policy, and have had the opportunity to review or receive a copy of our Privacy Practices.
By signing below, you acknowledge you have listed all pertinent information, read and understand our Cancellation Policy, and have had opportunity to review or receive a copy of our Privacy Practices.
Patient/Responsible Party Signature:

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Date:

MonthDayYear
Date
Should be Empty:

Insurance Company

Sorry, you will not be able to make an appointment at our office, as we do not participate with your plan.

Policy Holder

CANCELLATION POLICY: