Patient Contact Information
Name
Last Name
First Name
Middle Name
Street Address: City: State: ZIP:
Home Phone: ( ) Cell Phone: ( )
Primary Phone:
Date of Birth: / / Age: Social Security #: / /
Ethnicity: Language: Do you need an interpreter? ?
Occupation:
Employer Name: Employer Phone Number: ( )
Are you a student?
Marital Status
Marital Status Spouse/Partner’s Name:
Email and Text Messages
Email Address: Do you receive text messages?
Insurance Billing Information
PRIMARY Insurance Company Name:
Insurance ID Number (Policy Number): Group ID:
Name of Guarantor Relationship
SECONDARY Insurance Company Name:
Insurance ID Number (Policy Number):
Name of Guarantor Relationship
Referral Information
How were you referred to us?
Primary Care Physician / Family Doctor
Name City Phone Number
Emergency Contact Information
Emergency Contact Name: Relationship to Patient:
Street Address: City: State: ZIP:
Home Phone: ( ) Work Phone: ( ) Cell No
Pharmacy Information
Pharmacy Name: Street Address:
City: Zip: Phone ( ) Fax ( )

Consent to Examination • Authorization to Release Information • Assignment of Benefits • Financial Agreement

I hereby authorize the above physician to perform a consultation and examination, and to initiate diagnostic and therapeutic treatments that may be considered advisable or necessary. I hereby authorize the above physician to release to the insurance company or its representative, any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such medical or surgical care. I hereby give lifetime authorization for payment of insurance benefits to be made directly to the physician rendering service. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize these physicians to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

Your Name: Date:
Your Signature: Date: