Page 1 of 2 Please complete all required fields! Patient Information Patient Name: Invalid Input Date of Birth: Invalid Input SSN: Invalid Input Mailing Address: Invalid Input City: Invalid Input State: Invalid Input Zip Code: Invalid Input Primary Phone: Invalid Input Primary Phone Type: HomeMobileWorkOther Invalid Input Alternate Phone: Invalid Input Alternate Phone Type: HomeMobileWorkOther Invalid Input Email: Invalid Input Your email address will only be used to provide you information about events and classes we are hosting/sponsoring. We will not share this information. Employer: Invalid Input Please tell us how you heard about us: Invalid Input Occupation: Invalid Input Sex: MaleFemale Invalid Input Parent or Legal Guardian: Invalid Input Are you a veteran? YesNo Invalid Input Are you active or retired military? ActiveRetiredNeither Invalid Input Ethnicity: Invalid Input Marital Status Marital Status: MarriedSingleWidowedDivorced Invalid Input If Married, Spouse's Name: Invalid Input May we contact? YesNo Invalid Input Emergency Contact Name: Invalid Input Phone: Invalid Input Relationship: Invalid Input Next > Insurance Information Primary Insurance Insurance: Invalid Input Insurance Phone: Invalid Input Policy Number: Invalid Input Group Number: Invalid Input Policy Holder: Invalid Input Policy Holder DOB: Invalid Input Policy Holder’s SSN: Invalid Input Policy Holder’s Employer: Invalid Input Do You have Secondary Insurance? YesNo Invalid Input Secondary Insurance Insurance: Invalid Input Insurance Phone: Invalid Input Policy Number: Invalid Input Group Number: Invalid Input Policy Holder: Invalid Input Policy Holder DOB: Invalid Input Policy Holder’s SSN: Invalid Input Policy Holder’s Employer: Invalid Input PATIENT PAYMENT AGREEMENT I understand that I am responsible for my medical bill and accept responsibility for any charges not covered and paid by my insurance company or other third party resources. By signing below, I authorize the release of my medical records to the insurance carrier as may be necessary to determine benefits and to process claims for health care services provided to the above named patient. I authorize assignment of Medicare/Medicaid, other federal/state agents or any commercial insurance carriers to pay benefits directly to the provider of service(s). This is a Lifetime insurance authorization granting the provider authority to file claims on my behalf. In addition to the above patient payment agreement, I sign below acknowledging receipt of the office’s NOTICE OF PRIVACY PRACTICES Do you agree to the terms of this document?(*) I Agree Invalid Input Digitally Sign - Enter First and Last Name:(*) Invalid Input Date: Invalid Input Anti-Spam(*) Invalid Input < PrevSubmit
