• Patient Information

    The person seeing the physician
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  • Government regulations require us to ask the following:

  • Guarantor Information

    The responsible party
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  • Additional Information

  • Insurance Information

    Please bring your insurance card with you
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  • Emergency Contact

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  • Pharmacy

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  • Motor Vehicle Accident

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  • Work Related Injury

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  • If this is a work related injury but you prefer it not to be filed to your workers' compensation carrier, please note: It is your choice to ask us to file under your private insurance; however, we will be unable to go back and file to your work insurance. If that is your choice, please indicate and sign the acknowledgement below.

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  • Third Party Billing

  • Notice of Privacy Practices

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