EmailMe Form - NEW PATIENT INFORMATION

#1 Confidential Patient Information:
Today's Date
MM / DD / YYYY
Name
First MI Last
Phone
### - ### - ####
Age
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Gender
Which best described you:
Main Reason for Today's Visit
#2 Billing/Payment
If YOU are responsible for payment, please someone other than you is responsible for billing, please answer the following. If YOU are responsible for payment, skip this section.
Check all that apply to you or your immediate family (parents, siblings, grandparents)
Asthma
Cancer
Cardiac Disease
Diabetes
History of Back Pain
Hypertension
Psychiatric Disorders
Seizure Disorder
Stroke
#2 Billing/Payment
If YOU are responsible for payment, please someone other than you is responsible for billing, please answer the following. If YOU are responsible for payment, skip this section.
Who (other than you) is responsible for payment:
Relationship to Patient:
THEIR Phone #:
THEIR Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Do you have INSURANCE?
Yes
No
INSURANCE:
If you have insurance, please fill out this section:
Patient's relationship to Insurer:
Self
Spouse
Child
Other
Primary Insured's Name:
Primary Insured's Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Insurance Company:
Insurance Address:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Policy Number:
Group Number:
AUTHORIZATIONS:
Please list name and relationship of anyone with whom we may share confidential information (i.e. spouse, child, doctor, etc.)
Read ALL FIVE authorizations. Mark each one as you read and agree to them. Then sign and date this section.
I hereby authorize release of any medical information necessary to process this claim and request payment of insurance benefits either to mself or to the party who accepts assignments.
I authorize payment of any medical benefit from third-parties for benefits submitted for my claim to be paid directly this this office.
I authorize the direct payment to this office of any sum I now or hereafter owe this office by my attorney, out of proceeds of any settlement of my case and by any insurance company contractually obligated to make a payment.
I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself.
Furthermore, I understand that this office will prepare any necessary reports and forms to assist in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account.
I clearly understand and agree that a services rendered to me are charged directly to me and that I am personally responsible for payment.
I also understand that if I suspend or terminate my care and treatment, any fees for products or professional services rendered wil be immediately due and payable.
Patient Signature
Clear
Guardian Signature
Clear
Are you currently using or do you have a history of illegal drug use?
Yes
No
Do you feel you are at risk for falls or falling injuries?
Yes
No
Check all symptoms you are currently experiencing
Allergy
Cardiovascular
Chest Pain
Connective Tissue
Diabetes
Eating Disorder
Ear / Nose / Throat
Eye
Fever
Gastrointestinal
Genitourinary
Hemtalogical
Lymphatic
Musculoskeletal Pain
Neurological
Psychiatric
Respiratory
Skin
Weight Gain
Weight Loss
Please describe your alcohol consumption
Daily
Weekly
Monthly
Occasionally
Rarely
Never
Single Line Text

#1 Confidential Patient Information:

#2 Billing/Payment

#2 Billing/Payment

INSURANCE:

AUTHORIZATIONS: