Patient Information

Last Name 

First Name

Middle initial

Date of Birth [mm/dd/yyyy]

Address

Age

City

Sex

Select One Female Male

State 

Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Distr of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code 

Social Security Number

[123-45-6789]

Marital Status  

Select One Married Single

Driver's License #

Home Phone

Email Address

Employer

Work Phone

Occupation

Spouses Name

Referred by (name)

Referred by (address)

In Case of Emergency Contact:

Name

Phone

Relationship to Patient

Person Financially Responsible
COMPLETE ONLY IF DIFFERENT FROM PATIENT

Last Name

First Name

Middle Initial

Social Security Number

[123-45-6789]

Address

Date of Birth
[mm/dd/yyyy]

City

Home Phone

Email Address

State

Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DiIct of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Occupation

ZIP Code

Employer

Drivers License Number

Work Phone

Insurance Information
NOTE: These are REQUIRED FIELDS! Please enter "NA" if you are a cash patient or if the fields do not apply to you.

Medicare

No
Yes - Number:

Medical

No
Yes - Number:

Insurance Company Name

Insurance Company Address

Subscriber Date of Birth

Social Security Number

[123-45-6789]

Group #

Policy #

Subscriber Name (if not patient)

Relationship to Patient

Payment is expected at the time of service. For individuals with Medicare or PPO's with whom our office is contracted, please see below:

Assignment of Insurance Benefits
I hereby authorize and request my insurance company to pay directly to the Doctor the amount due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expense, I will be responsible for payment of the difference; and if the nature of the condition be such that it is not covered by the policy, I will be responsible to the Doctor for payment of the entire bill. If it should be necessary to initiate legal proceedings to collect any unpaid amount, I will be responsible for all collection fees plus all interest charges.
I have read and acknowledged the above

If you have any questions regarding this form or the questions, please call (818) 907-7546 and speak with one of our registration specialists. Our office is open Monday through Friday from 8:15 am to 5:30 pm.