Registration Form

Complete the following information and our scheduler will promptly contact you to schedule your appointment. We will need a copy of your current insurance card.  When your insurance changes or if your employer gives you a new insurance card you are required to present the new information to us immediately.  We will be happy to file an insurance claim on your behalf, but filing your insurance does not remove you from responsibility for your bill.  The patient is still responsible for any portion of the bill not covered by the insurance contract.  We will verify your insurance benefits prior to your appointment.  You will be responsible for pre-payment of your deductible and/or co-pay.  

First name:

Middle name:

Last name:

Birthdate: __/__/____

Age:

Gender: Male/Female

Home Address:

City/ State /Zip:

Home Phone:

Cell Phone:

Work Phone:

Email:

Social Security #:

Martial Status:

Your Nationality:

Your Native Language:

Employer:

Employer Address:

City/State:

Referred to this office by:

For Treatment of what part of your body?
(Right/Left_________):

Date Injured?

How were you injured?:(Auto,work,fall,etc)

Any Treatment?/ X-rays/ When?:

Responsible Party Name/Address:
(If patient is a child under 18 years of age)

Insurance Company Name or Self Pay:

Insurance Co. Address:

Insurance Co. Phone #:

Policy Holder Name & Relation to Patient:

Policy Holder DOB & SS#:

Contract#:

Group#:

Comments:

I authorize the release of any medical or other information necessary to process all claims. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the physician or supplier for services rendered.
(Please type your name as your electronic signature)