Established Patient Packet

Please correct the errors described below.

Established Patient Information

Bring your photo ID

Financially Responsible Party

Insurance Bring your insurance card[s]

Only complete if insurance has changed since last visit.

Insurance #1 (Primary Insurance- This will be filed first)

Insurance #2 (Secondary Insurance-This will be filed after primary insurance pays)

Emergency Contact

Established Patient History

Established Patient History (Blank answers will be recorded as no/negative in your electronic record.)

My responses are accurate for use in my medical decision making.

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.