Patient Information

Employment Information

Spouse Information

Who may we contact in case of emergency?

Nearest Relative not living with you?

Referring Physician

Primary Insurance Information

Secondary Insurance Information

Contact Method

I authorize the release of medical or other information about me to the above listed insurance provider(s). I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

Copays, co insurance, and/or deductibles are due at time of service. A $15.00 processing fee will be added for co- pays not paid at time of service. All accounts should be paid within 90 days of insurance being posted to prevent further action. I agree to pay any collection or attorney fees owed in addition to court costs if charges are not paid within the agreed upon terms and legal action is necessary to effect collection. No-show and late cancellation Fee. If an appointment is cancelled with less than 24 hours notice or you do not show up for a scheduled appointment, a $50.00 fee , not for any service, but for the lost opportunity to see another patient, will be added to your account.

I certify that I have read all of the above and the information given is true.

This practice is required to provide quality reporting data to the government. You can choose to opt out to exclude yourself with the checkbox below. Otherwise, you choose to share your information.