Patient Profile

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Patient Information

Emergency Contact

Insurance Information ** Please fill out completely even if cards have been scanned in**

Primary Insurance

Secondary Insurance

Confidential Communication

I wish to be contacted in the following manner (Check All That Apply):

Please initial the following items and sign at the bottom:

Missed Appointments: In fairness to other patients and the doctor, we require at least 24 hours notice to cancel appointments. If you miss three appointments, you will be dismissed from the practice. There may be a charge of $100.00 for no-show appointments.

Release, Assignment and Statement of Responsibility

I authorize release of any information necessary to process my insurance claims, and assign/request payment to be made directly to the provider(s). I understand that I may revoke this consent at anytime in writing to this office. I further understand that I am responsible for payment for all services rendered to me, or any patient for which I am listed as the responsible billing party.

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