Patient Name _____________________________________Age ______Date of Birth ______________

Address __________________________________City ______________ State ____Zip ____________

Please circle marital status: Single , Married , Separated , Divorced or Widowed

Employer _______________________________________Occupation __________________________

Is insurance provided through your employer? Yes No   Through your husband's employer? Yes No

Husband's Name __________________Soc. Sec. # ___________________Date of Birth____________

Employer____________________________ Occupation ______________ Phone _________________

Nearest relative not listed above ___________________________________Relationship ___________

Address _________________________________________________Phone _____________________

Person to notify in emergency if none of the people above can be reached _______________________

Address _________________________________________________Phone _____________________

FEE POLICY: To control costs we ask patients to pay their co-payment at the time of service.

MEDICAL RECORD RELEASE/ASSIGNMENT OF BENEFITS

I hereby assign all medical and surgical benefits, including major medical benefits that I am entitled to:  Medicare, private insurance, and any other health plans, to the physician(s). This assignment remains in effect until revoked 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 if covered or not or paid by said benefits as well as all collection fees and legal fees incurred in a collection process. I hereby authorize said assignee to release all information necessary to secure payment.

DATE ________________ SIGNED _____________________________________________