New Patient Packet

Patient Name

Age

Birth Date

Street Address

City

Zip

SS#

Mailing Address

City

Zip

MOTHER OR LEGAL GUARDIAN

Mother’s Name

Legal Guardian

Yes No

Birth Date

Street Address

City

Zip

Home/Cell Phone

Work Phone

Email Address

SS#

Employer

Address

Email Address

FATHER OR LEGAL GUARDIAN

Father’s Name

Legal Guardian

Yes No

Birth Date

Street Address

City

Zip

Home/Cell Phone

Work Phone

Email Address

SS#

Employer

Address

Email Address

In Case of Emergency (Friend or Relative not listed above)

Name

Address

Home & Cell Phone

Work Phone

Relation

INSURANCE INFORMATION (A copy of ALL Insurance cards is required for filing purposes.)

Primary Insurance

Name of Insured & SS#

Group #

Insured’s DOB

Insurance ID#

Secondary Insurance

Name of Insured & SS#

Group #

Insured’s DOB

Other Insurances

How did you hear about us?

Radio Web Mailers Events Newspaper Magazine Referral

How would you like us to communicate with you?

Home Phone Cell Phone Work Phone Email

Your receipt for each visit will contain all the information needed to process an insurance claim. Please remember that insurance is a method of reimbursing you for fees paid to the doctor and is not a substitute for payment.

I hereby assign to Sandra Maerzacker, MD all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. The above registration information is correct to the best of my knowledge and I understand and accept the above payment policy.

I hereby authorize Sandra Maerzacker, MD to release any pertinent medical information to my insurance carriers for myself or dependents.

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 of Parent or Guardian

DATE

Your information will be encrypted.