New patient Registration Form

Full Name*

First NameLast Name

E-mail

Sex*

FemaleMale

Phone Number*

Area CodePhone Number

Other phone

Area CodePhone Number

Date of Birth*

MonthDayYear

Social Security Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

I will pay by

Health Insurance Name ( type not applicable if no insurance)*

Insurance Phone Number on the insurance card*

Health Insurance ID number*

Insurance Group Number

Upload insurance card

Upload a File

Upload your ID or driver license

Upload a File

Appointment Date

MonthDayYear

Appointment Time

:HourMinutesAM/PM Option

Clinic you have appointment at*

I voluntarily consent and authorize Houston Family Physicians PA to provide me and my dependents with medical care and perform diagnostic tests.Consent for Minor Child. The undersigned hereby requests and authorizes outpatient clinical care to perform diagnostic tests and render treatment to the patient, a minor child. This authorization extends to all other clinics, doctors, and office staff members and is intended to include radiographic examinatio at the doctor's discretion. As of the date below, the undersigned states and vows to have the legal right to select and authorize health care serices for the minor child name above. If applicable under the term and conditions of divorce, separation or other legal authorization, the consent of the spouse or former spouse or other parent is not required. If authority to select and authorize this care should be revoked or modified in any way, the undersigned does hereby agrees to notify Houston Family Physicians PA as soon as is possible. Financial responsibility and assigment of benefits. All professional services rendered are charged to the patient and are due at the time of services, unless other arrangement have been made in advance with our practice financial advisor. Necessary form will be completed to help expedite insurance carrier payment. However, I am resposible for all fee, regardless of insurance coverage.I hereby assigned all medical and surgical benefits to include major medical benefits to which I am entittled. I hereby authorize and direct my insurance carriers including Medicare, Medicaid, private insurance and any other health medical plan to issue payment checks to Houston Family Physicians PA for medical services rendered to myself and or my dependent regardless of my insurance benefits if any.I hereby authorize Houston Family Physicians PA to release any information necessary concerning my illness and treatment, to process my insurance claim and to allow photocopy of my signature to be used to process my insurance claim for the period of life time.The insurance information furnished here represent a full disclosure of the insurance third party benefit to which I am entitle. I understand that failure to disclose precertification or second opinion requirement for any and all plans to which I subcribe may cause to incur full liability for professional charges, as a reult of non-payment by any carrier.By click submiting this form, I agree with all above terms. Please type your name below. This will serve as your electronic signature.*

Houston Family Physicians PA

New Patient Registration Form