New/Annual Registration

New/Annual Registration
New/Annual Registration
Which Doctor would you like to be seen by?

Dr. Pilkington Dr. Smith Dr. Cudjoe Dr. Bonnaci
Name *

First Name Middle Name Last Name
Preferred Name
Prefix
Suffix
D.O.B *

Month Day Year
SSN *
Sex *

Male Female
Race *
Marital Status *
Ethnicity *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
On this date, I authorize Great Lakes Surgical Associates to contact me or leave a message at the following contact methods:

Home Work Cell Email
Preferred Method of Contact *

Text Message Email Home Phone Cell Phone
Employer
If patient is a minor: Parent/Legal Guardian's Name: *
Relationship *
D.O.B *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Care Physician's Name *
Enter N/A if you do not have a PCP
Phone
Please enter a valid phone number.
City, State
Referring Physician's Name
Phone
Please enter a valid phone number.
City, State
Emergency Contact & Relationship *
Phone *
Please enter a valid phone number.
Primary Insurance:
Policy #
Group #
Subscriber: Name, Relationship, D.O.B:
Secondary Insurance:
Policy #
Group #
Subscriber: Name, Relationship, D.O.B:
Pharmacy
Phone
Please enter a valid phone number.
Consent to Share Medical Information
On this date, I, name , do hereby grant permission for my physician or his/her staff to discuss information regarding any and all treatment results to:
Name *
Relationship *
Name
Relationship
Name
Relationship
Name
Relationship
I understand this contact permission form is to be placed in my medical chart and used for the expressed purpose herin. *

Agree
Notice of Privacy Practices
I have read the above policy and agree to their terms *

Agree
Financial Policy
I have read the above policy and agree to their terms *

Agree
The undersigned Patient or legally authorized representative ("Agent") of the Patient acknowledges that he or she personally received a copy of the Great Lakes Surgical Associates Notice of Privacy Practices on the date indicated below.
All Patients: Authorization to Release Information & Assignment of Benifits

I authorize the release of any medical information necessary to process my medical service claims. I permit a copy of this authorization to be used in place of the original. I hereby authorize Great Lakes Surgical Associates (GLSA) to apply for benefits on my behalf for covered services rendered by my physician. I request that payments from my insurance company be made directly to GLSA. I certify that the information I have reported regarding my insurance coverage is correct. I understand I can revoke this authorization at any time by submitting a written request. I hereby state that all the above information is valid and accurate to the best of my knowledge.
Signature: *
Date

Month Day Year
Information about Agent (attach appropriate documentation):
Agent
Title
Agent Documentation

Cancel of
Should be Empty:

New/Annual Registration

Consent to Share Medical Information

Notice of Privacy Practices

Financial Policy