General Surgery at Northpointe

Available Forms

Colonoscopy Screening Form General Surgery at Northpointe History and Physical General Surgery at Northpointe Patient Registration Form Miralax and Dulcolax Bowel Prep for Colonoscopy

General Surgery at Northpointe Patient Registration Form

Patient Registration Form

Date *

Please Include Today's Date

Home Phone *

Please include home telephone number

Cell Phone

Please include if applicable

Name *

Last, First, Middle

E-mail *

Address *

Please include PO Box if needed

Sex *

Female

Male

Date of Birth *

Race

Optional

Responsible Party if Minor

Please include Parent's first and last name, if patient is under 18 years of age.

In case of emergency who should we notify? *

Please include first and last name, relationship, and contact number.

Primary Insurance

Insurance Company *

Policy Number *

Group Number

Please include if possible

Policy Holder *

Individual whom carries the insurance

Date of Birth *

Relationship to Patient *

Is patient covered by secondary insurance? *

Yes

Insurance Company

Policy Number

Group Number

Please include if possible

Policy Holder

Individual whom carries the insurance

Date of Birth

Assignment and Release

I, the undersigned certify that I (for my dependent) assign all insurance benefits to General Surgery at Northpointe, LLC if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the name facility to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all insurance submissions.

Patient/Responsible Party Signature

Please leave blank to sign at the time of appointment.

Relationship

Date

* Required field