Primary insurance

Co Name:

Address:

City:

State:

Zip:

Home Phone #

Cell Phone#

Email:

ID# (Plan Local or Policy)

Insured's Name:

Relation:

DOB:

Insured's employer:

Secondary Insurance

Co Name:

Address:

City:

State:

Zip:

Phone #

ID# (Plan Local or Policy)

Insured's Name:

Relation:

DOB:

Insured's employer:

Person ultimately responsible for account

Name:

Relation:

Billing Address:

City:

State:

Zip:

DL#:

Work Phone #

Payment method:

Cash

Check

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered.
I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).

Initials

IN EVENT OF EMERGENCY

Whom should we contact?

Relation:

Home Phone #:

Work Phone #:

Cell Phone #:

Who is your Medical Doctor?

Medical Doctors Phone #:

E-Signature

Please sign electronically below.

Clear Signature

INSURANCE INFO

Primary insurance

Secondary Insurance

ACCOUNT INFO

Person ultimately responsible for account

IN EVENT OF EMERGENCY

E-Signature

Take/upload one or more pictures of your Insurance card

INSURANCE INFO

Primary insurance

Secondary Insurance

ACCOUNT INFO

Person ultimately responsible for account

IN EVENT OF EMERGENCY

E-Signature

Take/upload one or more pictures of your Insurance card

E-Signature Consent