Patient Registration

Today's Date

Birth Date

Patient Name

Single Married Divorced Widowed Other

Home Phone

Cell

Gender

M F

Address

City

State

Zip

Dr. Smith periodically sends updates via email

Employer

Occupation

Business Address

Phone

**Please note that we are not contracted with any Insurance at this time. We are not a Medicare provider and are not contracted with any State Funded policies.

Name of Insurance

Group #

Membership ID

Policy Holder Name

Birth Date

Emergency Contact

Relationship

Phone

Who may we thank for referring you to our office?

Consent to treat: I understand by signing below I consent to medical treatment performed by Stephen L Smith, MD and his staff. I understand that no guarantee has been made regarding results of such treatment.

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 Patient or legally authorized individual

Date

Relationship to Patient if signed on behalf

Your information will be encrypted.