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Patient Name: (Last)
(First)
(MI)
Name you prefer to be called:
Patient Address:
City:
State:
Zip:
Home Phone:
Beeper/Cellular:
Birthdate:
Not Set
Age:
Sex:
Country of Birth:
Country of Parents’ Birth:
Education:
(Circle the highest level achieved)
Employment Information:
Patient Employer:
Occupation:
Employer Address:
City:
State:
Zip:
Work phone No:
Ext.
Social Security:
Drivers License:
In Case of Emergency:
Name:
Relationship:
Phone:
Patient’s Spouse:
Phone:
Family Physician:
Phone:
Referred by:
Finanial Policy:
Thank you for selecting Dr.for your health care needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept Visa, MasterCard and checks.

I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.

I have read and understand all of the above and have agreed to these statements.
Patient's Signature
Not Set
Date
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