Personal Information
Name
First Name
Last Name
Email
example@example.com
Birthdate
-
Month
-
Day
Year
Date
Home Phone
-
Area Code
Phone Number
Cell
-
Area Code
Phone Number
Preferred method of contact
Home Phone
Cell Phone
Email
Other
Method of contact for appointment reminders, receipts and general communication.
*
I authorize Dr. Joe & Associates to use my cell or email for appointment reminders, receipts and general communication.
Opt out of digital appointment reminders
Address
Street Address
Street Address Line 2
City
Province
Postal
Emergency Contact
Phone Number
-
Area Code
Phone Number
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Primary Insurance Information
At the recommendation of the RCDSO, our office is an non-assignment office. This means that you are responsible for payment of our professional services and your insurance company pays you directly for any benefit you may have. If possible, we will gladly submit your claims to your insurance on your behalf to assist you with speed of reimbursement.
Not applicable
Insurance Company
Subscriber's Name
Birthdate
Group or Policy #
Certificate #
Employer
Patient's relationship to subscriber
Self
Spouse
Child
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Secondary Insurance Information
If applicable
Not applicable
Insurance Company
Subscriber's Name
Birthdate
Group or Policy #
Certificate #
Employer
Patient's relationship to subscriber
Self
Spouse
Child
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Request for confidential communication
Please check all that apply
You may discuss my healthcare with healthcare providers
You may discuss my healthcare with insurance companies
You have my permission to contact me at home
You have my permission to contact me via cell phone
You have my permission to contact me at work
You have my permission to contact me via email
Signature
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Month
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Date
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Hour
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Minutes
AM
PM
AM/PM Option
Submit
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