Patient Registration

Basic Information

Patient Name

Your Email Address

Address

Home Phone

Cell Phone

Sex

MaleFemaleOther

Date of Birth

Employer or School

Whom may we thank for referring you?

Emergency Contact Name

Emergency Contact Phone Number

Primary Insurance

Person Responsible for Account

Relationship to Patient

Date of Birth

Phone

Employer

Occupation

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with:

Insurance Company Name

I assign directly to Lauren Fox, FNP, BC, CCH all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named care provider may use my health care information, and may disclose such information to the above-named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits, or the benefits payable for related services. This consent will end when my current treatment plan is completed, or one year from the date signed below.

Patient or Personal Representative

Today's Date

Relationship to Patient