New Patient Information

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New Patient Information

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  • Please enter a number from 1 to 99.
  • Which Physician you are here to see?

  • IS THIS VISIT RELATED TO AN ON THE JOB INJURY?

  • If the patient is a minor or student:
  • PERSON RESPONSIBLE FOR PAYMENT, IF NOT ABOVE:

  • PLEASE PROVIDE THE RECEPTIONIST WITH YOUR INSURANCE CARD AND DRIVER'S LICENSE. IN ORDER TO CONTROL BILLING COSTS ALL OFFICE VISITS ARE TO BE PAID AT TIME OF SERVICE UNLESS YOU ARE ON A MANAGED CARE PROGRAM. AUTHORIZATION: I hereby authorize the physician indicated above to furnish information to insurance carriers concerning the illness/accident and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not covered by my insurance carrier.