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Patient Information

What title do you identify with?
Mr.
Ms.
Mrs.
Other
Date of birth
Month
Day
Year
Sex
Male
Female
I'd rather not say
Marital status
Are you currently employed?

(If yes, show:)

Are you currently a student?

(If yes, show:)

Information from the Financial Manager

Are you responsible for payments?

(If you answered no, complete the details of the financial manager)

Date of Birth
Month
Day
Year

Insurance Information

Do you have health insurance?

(If yes, complete the following information)

Insurance start date
Month
Day
Year
I agree that the doctor will receive payment directly from my insurance company for the services provided.
Yes
I understand that I am responsible for payment if my insurance does not cover the full amount.
Yes
I agree that I must cancel appointments at least 24 hours in advance to avoid additional charges.
Yes
I agree to the $10.00 charge if my check is returned by the bank.
Yes
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