PLEASE FILL OUT ALL BLANKS – IF LEFT BLANK WE WILL ASK YOU TO FILL IT OUT. IF IT DOES NOT APPLY TO YOU, PLEASE PUT (N/A). WE NEED ALL INFORMATION FOR BILLING PURPOSES.
(Please provide email or mobile number for courtesy appointment reminder)
(Please indicate a friend or relative not living at the same address that we may contact)
Responsible Party and Billing Information
Patient's Parent or Legal Guardian if the patient is a minor under 18 years of age. This is the person responsible for the patient.
By typing your initials below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Insurance Information: (Please provide all insurance cards and picture I.D. to Front Desk Clerk to copy/scan to your file). Your appointment will be rescheduled if you do not have appropriate ID.
Please provide us with your preferred Pharmacy Information.
By typing your name and/or initials below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I fully understand and acknowledge that Fort Worth Perinatal Associates, P.A. is a specialty practice which I have been referred to by my primary OB physician, on a consultation basis only. My Obstetrician will continue to care for me during my pregnancy and will be delivering my baby. I also understand that it is vital for me to continue seeing my Obstetrician for regularly scheduled appointments, even if I have an appointment with Fort Worth Perinatal Associates, P.A. the same day or same week.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.