Patient Demographic Information

18 Years and Older

Please correct the errors described below.

Add Additional Guardian

Authorization for Treatment and Release of Information

Acknowledge of Receipt of Consent to Use and Disclose Health Information

ATTENTION

Though you may still be covered under your parent’s insurance, you, as an adult, are solely financially responsible for any and all payments: copay, coinsurance, or deductible that your insurance deems as your responsibility.

My signature below indicates I am the patient listed above, that I have provided accurate information to the best of my knowledge and I understand and agree to the provision above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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