GENERAL INFORMATION

Date:

Last Name:

First Name:

Age:

Sex :M :F
D.O.B: //

Address:

City: State:

State:

Zip:

Home #:

Cell. #:

Email:

Emergency contact person:

Emergency contact phone:

Parent/Guardian Signature:

Occupation:

Employer Name:

Phone:

Emergency contact phone:

My condition is related to: Work Auto Accident State
Other

Social Security #:

D.O.B: //
Single Married

Work status: Currently Employed Retired Disabled ( Total or Temporary) Student (P/T or F/T)

Referral Info **ALL INFO REQUIRED**

How did you hear about us?

Primary or referring Physician Name:

Street Address:

City:
State:

Zip:
Phone:

Fax:

Email:

Do you have a follow up appointment with this physician?

If yes, when?

Payment info: (check only one box)

I am paying by CASH, CHECK, CREDIT and would like a....
30% discount by paying at the time of service
Payment plan. Fees may apply.

I have INSURANCE and would like to...
Have a deal directly with them. I will assign my benefits to you by completing the Assignment of Benefits Form. Fees may apply. The following information is required prior to first visit.

My coinsurance/copay is $
My deductible is $
Get a 30% discount by paying the entire bill at the time Of service. I'll get reimbursement on my own. (Ask the front desk person for details)

I have an ATTORNEY and would like to...
Get a 30% discount by paying up front. I'll get reimbursement after my case settles.
Wait until my case settles before paying. I will complete the "Attornet Lien" form fees may apply.

Credit Card on File

Safe and secure. I understand I will be notified of any and akk charges prior to processing.

Visa:
MC:
Amer X:
Discover card

Name on card:
Exp Date:
CVV Code: