Patient Information Form / Contact authorization

Parent/Guardian (1) INFORMATION

Last Name

Middle

First Name

Address

City

State

Zip

Home Phone

Cell Phone

Employer

Occupation

Work Phone

Social Security #

Birthdate

Insurance Carrier

Primary Secondary

Parent/Guardian (2) INFORMATION

Last Name

Middle

First Name

Address

City

State

Zip

Home Phone

Cell Phone

Employer

Occupation

Work Phone

Social Security #

Birthdate

Insurance Carrier

Primary Secondary

What is your preferred way to be contacted? (Check all that Apply)

Home Phone

Home Address

(1) Cell

(2) Cell

(1) Work

(2) Work

Other

If other, Please Specify

PLEASE LIST ALL CHILDREN WHO ATTEND THE PRACTICE INCLUDING PATIENT(S)
SEEN TODAY

Add Additional Name

FINANCIAL RESPONSIBILITY and CONTACT INFORMATION AUTHORIZATION

As a courtesy, our practice will file your claim electronically with your insurance company. You will be billed for charges not covered by your insurance company and payment is expected within thirty (30) days of receipt of our billing statement. Delinquent accounts may be placed with a collection agency. In the event that your unpaid balance is turned over to a collection agency for recovery, collection and attorney fees will be added to your balance. Returned checks will incur a $30.00 service fee.

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.

Signature

Date

Your information will be encrypted.