Patient Registration Form

Please correct the errors described below.

In case of Emergency, contact:

Responsible Party:

Insurance Information

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.

NEW PATIENT INFORMATION

Past Medical History

Symptoms and Medical Conditions

Family History

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