New Patient Information Form

Mailing Address/Direccion De Correo

Phone Contact / Telefonos De Contacto

HEALTH INSURANCE/ SEGURO MEDICO

AUTO INSURANCE/SEGURO DE AUTO

ENGLISH: I represent and affirm that the above information is true and correct, and it is my understanding that Central Florida Pain & Rehab Clinic is relying on the above information that I have provided. I have read the “Consent for Treatment, Acknowledgment of Liability and Assignment of Benefits” forms on the following page and as the patient, or patient’s authorized representative of general agent for the purpose of signing this document. I hereby accept its terms.

ESPAÑOL: Declaro y afirmo que la información anterior es verdadera y correcta, y es mi entendimiento de que Central Florida Pain & Rehab Clinic se basa en la información anterior que he proporcionado. He leído los formatos anexos " Consent for Treatment, Acknowledgment of Liability and Assignment of Benefits " y que tanto el paciente como su representante autorizado para firmar este documento aceptan sus términos.

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