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Available Forms

**NEW PATIENT (1) - REGISTRATION FORM

NEW PATIENT REGISTRATION

NEW PATIENTS ONLY!!! Please make sure you fill out all THREE (3) forms labeled "New Patient" (see list on the left). Submit all 3 forms: NEW PATIENT (1) REGISTRATION; NEW PATIENT (2) HEALTH QUESTIONNAIRE; and NEW PATIENT (3) ANNUAL HEALTH SCREENINGS

DEMOGRAPHICS

How do you choose to identify and what are your choice pronouns, if any?
Enter "NONE" if you do not use Email
 

HEALTH INSURANCE

If NO, skip to the Financially Responsible Party section. If YES, please answer the following questions regarding your primary health insurance plan.

Primary Health Insurance

 
Who is the primary policyholder?
 
Primary Policyholder Date of Birth
 
 
Primary Insurance ID
Primary Insurance Group #
 
If No, Skip to Financially Responsible Party Section. If YES, please answer the following questions regarding your secondary health insurance plan.

Secondary Health Insurance

 
Primary Policyholder
 
Primary Policyholder Date of Birth
 
 
Secondary Insurance ID#
Secondary Insurance Group #
 

Financially Responsible Party

Name of the person responsible for paying medical bills
 
 

If the patient is NOT financially responsible, please answer the following regarding the financially responsible party:

Address of financially responsible party (if not the patient)
Phone # of financially responsible party (if not the patient)

Signature

By my signature below, I confirm that I understand that my insurance coverage is a relationship between my insurance company and myself, and I agree to accept financial responsibility for charges incurred that are not reimbursed by my insurance company. I understand that I may be billed for "No Shows" or appointments not cancelled within 48 hrs prior to the appointment time.

If patient is under the age of 18, must be signed by financially responsible party.
mm/dd/yyyy

Click SUBMIT FORM and then complete the next form called "NEW PATIENT (2) - HEALTH QUESTIONNAIRE"

* Required field