New Patient Registration Form

Patient Name *

First

Last

Date of Birth (mm/dd/yy) *

Age *

Email *

Gender *

Patient Street Address *

City *

State *

Zip Code *

Social Security Number

Marital Status

Cell Phone Number (xxx-xxx-xxxx)

Patient Employer

Patient Occupation

Responsible Party Name (Different from Patient)

First

Last

Responsible Party Address is Same as Above

Yes
No (Fill out Address Below)

Responsible Party Street Address

Responsible Party City

Responsible Party State

Responsible Party Zip Code

Responsible Party Employer

Responsible Party Occupation

Responsible Party Cell Phone (xxx-xxx-xxxx)

Spouse / Other Parent Name

First

Last

Are you the patients:

Spouse / Other Parent Street Address is:

Same as Patient
Same as Responsible Party
Different (fill out address below)

Spouse / Other Parent Street Address

Spouse / Other Parent City

Spouse / Other Parent State

Spouse / Other Parent Zip

Spouse / Other Parent Occupation

Spouse / Other Parent Employer

Spouse / Other Parent Cell Phone (xxx-xxx-xxxx)

Primary Name of Insurance Company

Primary Type of Insurance

Primary Insurance Card Holder Name

First

Last

Primary Insured Date of Birth (mm/dd/yy)

Primary Insurance Claims Street Address

Primary Insurance Claims City

Primary Insurance Claims State

Primary Insurance Claims Zip

Primary Insurance Claims Phone Number (xxx-xxx-xxxx)

Primary Insured Social Security Number or Identification Number

Primary Insurance Group or Policy Number

Primary Insurance Claim Number

Secondary Name of Insurance Company

Secondary Type of Insurance

Secondary Insurance Card Holder Name

First

Last

Secondary Insurance Claims Street Address

Secondary Insurance Claims City

Secondary Insurance Claims State

Secondary Insurance Claims Zip

Secondary Insurance Claims Phone Number (xxx-xxx-xxxx)

Secondary Insured Social Security Number or Identification Number

Secondary Insurance Group or Policy Number

Secondary Insurance Claim Number

Payment is expected at the time of service unless other arrangements have been made. Any balance not paid by the end of the month is subject to a $15 fee. As a courtesy of this office, your insurance will be billed, in which case you will be responsible for your deductible and co-payment at time of service. It is your responsibility to contact your insurance company to find out what your plan limitations are. In the event that it becomes necessary to assign this account for collection of your past due account, I agree to be responsible for all costs of collection including a 30% of your outstanding balance fee and all legal fees entailed in that process. *

I Understand

The above information is warranted to be true. I agree to be responsible for the charges incurred. If insurance is available, I authorize release of information for the purpose of filing claims, and also authorize payment of benefits directly to Melissa Gonzales. *

I Agree

Signature of Responsible Person (By Typing Your Name, You are Electronically Signing) *

First

Last

Today's Date (mm/dd/yy/) *

Message