We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill out this form as completely as possible.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.
I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
I understand that where appropriate, credit bureau reports may be obtained.
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