New Patient Registration

Referred By
How did you hear about us?
Primary Care Provider Name/Office:
Date

MonthDayYear
Date
Patient Information
Patient Full Name*
Social Security No. (If known)
Date of Birth*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Phone Number*
Pharmacy Phone Number
Parents / Responsible Party
Name*
Relationship to Patient*
Phone Number*
Employer
Email Address*
example@example.com
Spouse's Name
Relationship to Patient
Spouse's Employer
Spouse's Phone Number
In Case of Emergency
Name*
Relationship*
Phone Number*
2nd Person's Name
2nd Person's Relationship
2nd Person's Phone Number
Financial Responsibility
I understand that I am financially responsible for all charges. Payment for services is due at time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, money orders and most major credit cards.
Signature*

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Date

MonthDayYear
Date

Insurance Information
Patient Name
Sex

MaleFemale
Date of Birth

MonthDayYear
Date
Age
Social Security Number (if Known)
Primary Insurance
Insurance Company
Insured Name
Relation to Patient
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Social Security Number
Insurance Claims Address
Pre-Certification Phone Number
Policy Number
Group Number
Secondary Insurance
Insurance Company
Insured Name
Relation to Patient
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Social Security Number
Insurance Claims Address
Pre-Certification Phone Number
Policy Number
Group Number
Assignment of Benefits
I hereby assign all medical and / or surgical benefits for private insurance (Not to include Medicare, unless specific arrangements have been made) to: Pediatric Plastic Surgery Institute. The assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I herby authorize said assignee to release all information to secure the payment.
Signature*

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Date

MonthDayYear
Date
Should be Empty: