Employer Authorization Form

Please take a moment to complete the following form with as much information as possible to assist our team with assuring a seamless process.

Please fill out the following information:

 

Home Phone:

Work Phone:

Cell Phone:

E-mail Address:

 

ALLERGIES TO MEDICATIONS:

CURRENT MEDICATIONS:

REASON FOR TODAY'S VISIT:

Primary Physician:

May we release information about this visit?
 Yes No

 

REGISTRATION FORM

 

Patient Information

Last Name/Apellido:

First Name/Nombre:

Middle/Initial:

 

Address/Direccion:

City/Ciudad:

State/Estado:

Zip/Codigo Postal:

 

Home Phone:

Alternate Phone:

 

Birth Date/Fecha de Nacimiento:

Social Security Number/Seguro Social:

Marital Status/Estado Civil:
 Married Single Divorced Widowed Child

 

Patient Employer:

Work Phone:

 

Guarantor/Spouse/Parent: This is the individual on the insurance card and/or an adult responsible for the bill if the patient is a minor.

 

Last Name/Apellido:

First Name/Nombre:

 

Birth Date/Fecha de Nacimiento:

Social Security Number/Seguro Social:

 

If the guarantor's/parent's address is different from the patient's, enter it here:

 

Address/Direccion:

Phone:

Emergency Contact:

 

Relationship to patient:

 

Address/Direccion:

Phone:

 

Primary Insurance Company:

Secondary Insurance Company:

 

PLEASE PRESENT YOUR DRIVER'S LICENSE AND INSURANCE CARDS TO THE RECEPTIONIST

 

Enter Security Code
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