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Address: City: State: Zip:
Phone:() Work Phone () Cell Phone ()
OK to leave message on recorder Yes No
Date of Birth: Social Security Number:
Check Appropriate Box: Minor Single Married Widowed Seperated Divorced
If Student, Name of School City/State FT PT
Spouse or Parent’s Name: Employer: Work Phone
How did you hear about us : Newspaper Internet Family/Friend Other
Person to contact in case of emergency Phone
Email Address
Name: Birthdate:
Address:
City: State: Zip: Phone:()
Employer: Work Phone:() SSN#
SSN#: Name of Employer: Work Phone:()
Address of Employer: City: State: Zip:
Insurance Company: GRP#: ID#:
Ins Co Address:: Ins Co. Phone:
------- DO YOU HAVE ANY ADDIONAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING -------
Name of Insured: DOB Relationship to Patient
THE RECEPTIONIST WILL ASK FOR YOUR INSURANCE CARDS AND COPAYMENT AT EVERY VISIT.
I hereby request and consent to treatment and services provided by the physicians of Fairlawn Family Practice, Inc and PPG and authorize all payments directly to Fairlawn Family Practice and or PPG for all medical services provided. I assume responsibility for any unpaid balance including non-covered services except limited by law. I authorize the release of any medical or other information necessary to process my medical claims with Fairlawn Family Practice and PPG. I understand and acknowledge that the medical records may contain information regarding psychiatric disorders, HIV, AIDs related conditions and alcohol/and or drug dependency/abuse. This authorization for release of information is valid unless revoked by written notice to Fairlawn Family Practice, Inc providing said notice is received prior to the release of information.
Patient/Legal Guardian Signature:: Date:
