Registration

Name *

First

Last

Responsible Party (If a minor)

First

Last

Home Phone

Cell Phone

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Sex *

Age *

Birthdate *

Occupation *

Employer/School *

Employer/School Address *

Address Line 1

Address Line 2

City

State

Zip Code

Employer/School Phone Number

Marital Status *

Single
Divorced or Widowed
Married
Separated

Spouse Name

Spouse Birthdate

Spouse Occupation

Who is Responsible for this account?

Relationship to Patient

Social Security Number

Spouse's Social Security Number

Do you have Medical Insurance? *

Yes
No

If Yes, please provide Name of Primary Insurer, Policyholder, Contract #, Group #, Subscriber #, and, if any, Secondary Insurer

In case of emergency, who should be notified? *

First

Last

Emergency contact phone number *

How did you learn of my practice?

Insurance Assignment and Release: By entering my name below, I certify that I have insurance coverage with the Insurer listed above. However, I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed. Please enter name of Beneficiary, Guardian, or Personal Representative below: *

Date *

Email *