Patient Registration Form

Date:

Full Name (Last, First, MI):

Birthdate:

Gender:

Male Female

Marital Status:

Single Married Divorced Widowed

Address:

City:

State:

Zip Code:

Cell Phone:

Home Phone:

Employer:

Occupation:

Work Phone:

Employer Address:

City:

State:

ZIP:

Referring Doctor:

In case of Emergency, contact:

Name:

Phone:

Relationship to Patient:

Address:

City:

State:

ZIP:

Responsible Party:

Name:

Birthdate:

Phone:

Relationship to Patient:

Address:

City:

State:

ZIP:

Employer:

Occupation:

Work Phone:

Address:

City:

State:

ZIP:

Insurance Information

Type of Insurance:

ID Number:

Group Number:

Name of Insured:

Type of Insurance:

ID Number:

Group Number:

Name of Insured:

Type of Insurance:

ID Number:

Group Number:

Name of Insurance:

CONSENT TO TREATMENT:

I authorize and direct Dr. Sayers to perform upon me injections, draw blood and/or any other procedure/treatment they may determine advisable for my well being in their office. I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the outcome of the procedures and/or treatment.

ASSIGNMENT AND RELEASE:

I authorize release of any medical information necessary to process an insurance claim. I agree to the responsible for any co-payments and/or services not covered by my insurance. I authorize payment of medical benefits to the physician or supplier of services.

NO SHOW POLICY:

No shows and same day cancellations are subject to a $50 charge.

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.

SIGNATURE/NAME:

Date:

NEW PATIENT INFORMATION

History of Present Illness

Describe your current problem:

List the medications that you take (include over the counter medicines):

List the medicines you are allergic to:

Past Medical History

List Surgeries, Procedures and Hospitalizations and year they occurred.

Last Complete Physical Exam - Year:

Please list all the physicians involved in your healthcare.