Patient Registration Form PLEASE FILL OUT COMPLETELY, THANK YOU Patient Name Date of Birth Male Female Home Phone: National Insurance Number: Island/State/Country: Language: Regular Doctor: Child lives with: School: Insurance Company: Policy Number: Group Number: Name in full: Relation to Child: Date of Birth: Marital Status: Street Address: P.O. Box/Zip Code: Home Phone: Cell: Email: Insurance Company: Policy Number: Group Number: Name in Full: Relation to Child: Date of Birth: Marital Status: Street Address: P.O. Box/Zip Code: Home Phone: Cell: Work Phone: Place of Employment: Email: Insurance Company: Policy Number: Group Number: As a courtesy, we will file your insurance claim for you, if a copy of your insurance card and a photo ID are provided at the time of service. If you are unable to provide this information you will be required to pay for your visit at the time of service. Payment of your estimated portion, such as deductible and co-pay is required at every visit. In addition to your visit, procedures may be performed such as suturing or administering injections. These are additional charges to your office visit. As such, these charges may be subject to a deductible and co-pay percentage. WE EXPECT PAYMENT IN FULL IN THE FOLLOWING CIRCUMSTANCES: (1) You do not have any insurance coverage. (2) You have not brought your insurance card (s) with you. (3) You have not met your deductible. (4) You receive procedures or treatments that are not covered by your insurance. (5) You have a poor payment history with our office. I hereby consent to have my child treated in this office. I hereby authorize my insurance benefits to be paid directly to the physician. I authorize the physician to release any information that is required in the processing of my claims. If my child has been referred to this office by another physician or if my child is being referred to another physician, I authorize the release of his/her medical record to that physician. Guarantor's signature and identification upload: I acknowledge and agree that I have read and agree to be governed by the financial responsibility statement on the last page of this document. I also acknowledge that I am responsible for all charges associated with the above patient and agree to pay each bill in full, including any amount not covered by the insurance company. PLEASE UPLOAD A COPY OF YOUR ID AND YOUR SIGNATURE BELOW. The file must be a pdf, jpeg, png, or gif. Send
