Today's Date

Preferred Language

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PATIENT INFORMATION

Patient Name

Is this your legal name?

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Brith Date

Patient Middle Name

(For insurance purposes, please provide name as it is on social security card.)

Age

Patient Last Name

Marital status

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Sex

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Address

Zip code

City

State

County

Home Phone Number

Cell Phone Number

Email Address

Social Security Number

Race or Ethnicity 

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Occupation

Employer

Employer's Address

Employer's Phone Number

INSURANCE INFORMATION

Policy holder’s name

Policy holders’ phone number

Policy holder's address (if different)

Relationship

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Policy holder's DOB

Policy holder’s employer

Policy holder's social security number

Please indicate primary insurance

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Policy Number

Insurance phone number

Group  Number

Insurance address

Please indicate secondary insurance 

(if applicable)

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Policy Number

Secondary insurance phone number

Group  Number

Secondary insurance dddress

IN CASE OF EMERGENCY

Name of emergency contact 

Relationship

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Cell Phone Number

LIFETIME AUTHORIZATION

Preferred Payment Method

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Electronic Signatures: Any signature hereto or to any other certificate, agreement or document related to this transaction, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary.

Patient / Guardian Signature

Date

CONTRACT FOR CARE

Electronic Signatures: Any signature hereto or to any other certificate, agreement or document related to this transaction, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary.

Patient / Guardian Signature

Date

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