Evolutionary Healthcare

Available Forms

Authorization to Release Protected Health Information Medical History Form New Patient Registration Form Prescription Refill Request

New Patient Registration Form

Please fill out this form completely. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name *

Middle Initial

Last Name *

Date of Birth *

SSN *

Sex *

Mailing Address *

City *

State *

Zip Code *

Primary Phone *

Email Address *

Occupation

Employer

Additional Information

Marital Status *

Married

Widowed

Divorced

Separated

Single

Living Domestic Partner

Other

Decline

Race *

American Indian

Asian

Black

Caucasian

Hispanic

Pacific Islander

Other

Decline

How did you hear of us?

Google Search

Word of Mouth

Social Media

Referral

Other

Contact Information

Emergency Contact Name *

Relationship to Emergency Contact *

Emergency Contact Phone Number *

Preferred Pharmacy Name *

Preferred Pharmacy Phone Number *

Preferred Pharmacy Address *

Initial to Accept *

We will Email Statements, Reminders, and Lab Results. Please Initial to Accept.

Insurance Information

Primary Insurance Company *

Policy Holder's Name, if Different From Patient Name

Patient Relationship to Policy Holder *

Policy Holder's SSN *

ID Number *

Group Number *

Responsible Party Information

Name of Person Responsible for Payment *

Relationship to Patient

Address

City

State

Zip Code

Primary Phone Number

ASSIGNMENT OF INSURANCE BENEFITS: I understand Evolutionary Health Care is billing my insurance companies as a courtesy. I authorize direct payment to Evolutionary Health Care of any insurance benefit. I understand the pre-authorization is not a guarantee of payment, and that I am financially responsible for any charges not paid by my insurer and I agree to pay any unpaid balances on my account no more than 90 days after date of service. In the event that payment in full for charges incurred is not paid within 90 days. I agree to pay $2.50 per billing cycle until the balance is paid in full. I understand that if my bill is not paid within 90 days my account will be forwarded to Collections. I agree to pay all costs of collection including a 50 percent collection fee, attorney fees, court costs and interest at the rate of 1.5 percent per month.

I agree to the E-Signature Agreement *

By selecting the I agree box, I consent to signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting I agree using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. By electronically signing below, I acknowledge the understanding and acceptance of the terms and conditions set forth in this E-Signature Agreement.

E-Signature *

Type your full name

Date *

* Required field