Psychology Center and Psychologists in Fort Myers, FL, SWFL Psychologists, Dr. Steven Cohen

Patient Registration Form
PATIENT INFORMATION
Patient Name

First NameLast Name
Birth Date

MonthDayYear
Age
Under 18?
Gender
Marital Status
Employment Status
Address
Phone Number
Format: (000) 000-0000.
Alternative Phone Number
Format: (000) 000-0000.
Email Address - Used for Patient Portal invitation and appointment reminders. Do not use junk email
Reason For Visit
Our office is dedicated to providing the best care possible. Please provide detailed information to help us to identify the most appropriate provider..
Referred by:
Office Location - please indicate which office you would prefer to be seen
Preferred Provider
Health Insurance information
I Would Prefer To Self Pay
Self Pay Rates are $220.00 for first visit, $200.00 for returning
I am using benefits from my Physician/Attorney Wellness Program
Please select if you are a physician or attorney and a member of your local professional association
Insurance Provider
Member ID
This is required to pull your insurance benefits
Insurance Provider Phone Number
This is usually a 800 number located on the back of your insurance card
Secondary Insurance Provider and Member ID - If Applicable
Policy Holders Name (If different than patient)
Policy Holders Date of Birth

MonthDayYear
Policy Holders Relationship to Patient
PARENT/LEGAL GUARDIANS
Please complete the following section if patient is under 18 years old or is under legal guardianship

If you are an adult completing this for yourself skip to submit form
1st Parent / Legal Guardian Name

First NameLast Name
Parent / Legal Guardian Birth Date

MonthDayYear
Phone Number

Area CodePhone Number
Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
2nd Parent / Legal Guardian Name

First NameLast Name
Parent / Legal Guardian Birth Date

MonthDayYear
Phone Number

Area CodePhone Number
Address (if different)

Street Address

Street Address Line 2

CityState

Zip Code
DateTime
Date

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

Patient Registration Form

Health Insurance information

PARENT/LEGAL GUARDIANS