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Registration Form

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    Section I:Patient InformationDate:


    Name: I Prefer to be called:

    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

    Section II:Responsible Party


    Relationship to Patient: Self Spouse Parent Other

    Name: Birthdate:

    Address:

    City: State: Zip: Phone:()

    Employer: Work Phone:() SSN#

    Section III:Insurance Information


    Name: DOB: Relationship to Patient:

    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

    SSN#: Name of Employer: Work Phone:()

    Address of Employer: City: State: Zip:

    Insurance Company: GRP#: ID#:

    Ins Co Address:: Ins Co. Phone:


    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:

    About Us

    We’re here when you need us. We offer same-day scheduling when you’re ill, and in addition to regular office hours, we see patients on Monday, Tuesday and Thursday evenings and also on Saturdays. Call us or visit us today.

    General office hours

    Monday and Tuesday 9am - 9pm;
    Wednesday 9am - 5pm;
    Thursday 9am - 9pm;
    Friday 9am - 5pm;
    Saturday 9am - noon;
    Closed on Sunday

    Address

    Fairlawn Family Practice
    50 North Miller Road
    Fairlawn, Ohio 44333

    330-836-9721
    Fax: 330-836-9627

    © 2018 Fairlawn Family Practice