Main Patient Form

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Patient Information

First Name

Last Name

Gender

Birth Date

Street

Apartment

City

State

Zip

Home Telephone

Cell

Have you ever been a patient of our practice?

Did you find our practice online?

Referred By

Preferred Pharmacy

Telephone

Personal Payment Type

Has a family member ever been a patient of our practice?

Driver’s Licence Number

Nearest relative not living with you

Telephone

Employer

Occupation

Business Telephone

In case of emergency, please contact

Telephone

Relation

Primary Insurance

Employer

Business Address

City

State

Zip

Business Telephone

Plan

Insurance Company Name

Address

City

State

Zip

Telephone

Group Name

Group #

Insured Party

Relation

Birth Date

Gender

S.S. #

Telephone

Address

City

State

Zip

Secondary Insurance

Employer

Business Address

City

State

Zip

Business Telephone

Plan

Insurance Company Name

Address

City

State

Zip

Telephone

Group Name

Group #

Insured Party

Relation

Birth Date

Gender

S.S. #

Telephone

Address

City

State

Zip

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

I have read and understand the entire Financial Policy document. I consent to all the terms and conditions contained herein and all of the terms and conditions of treatment and understand that it is my responsibility for assuring that the financial obligation of Patient’s care is fulfilled. I hereby accept financial responsibility for all charges incurred whether or not I have insurance coverage.

I acknowledge that I have received the Notice of Privacy Practices. I understand that the organization reserves the right to change their notice and practices and before implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

I have read and understand the entire Transvaginal Scan Policy and give my consent.

I have read and understand the entire Non-Disparagement Clause and give my consent.

I have read and give my consent for Things to know before your Appointment.