Review of Symptoms: Please choose any persistent symptoms you have had the past few months. Read through every section and choose “No problems” if none of the symptoms apply to you.
I / we do hereby consent to and authorize the performance of all treatments, surgeries and medical services deemed advisable by the physicians and staff of Langer Family Medicine, PA to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of insurance coverage. I furthermore agree to pay legal interest, collection expenses, and attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize Langer Family Medicine, PA to release information requested by insurance companies and / or its representatives. I fully understand this agreement and consent will continue until canceled by me in writing.
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
List all medications you are currently taking, including both prescription and non-prescription, and the dosage.