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ADULT & PEDIATRIC MEDICINE – ALLEN & FRISCO

PHONE: (972) 359-0000      FAX: (972) 359-1000      E-MAIL: MAIL@CLINIC2000.COM

New Patient Registration Form

Required fields are bolded with *.

Type of Patient * Adult Child
 
Gender * Male Female
Last Name *
First Name *
Middle Name
Address *
Apt. Number
City *
State *
Zip *
Home Phone *
Work/CEL Phone
Date of Birth *
Age
Social Security #
Driver License #
Driver License ST
Marital Status Married Single Other

 

Emergency Contact *  
Emergency Contact Phone *  
 

Responsible Party Information (Same As Above )
  (Do Not complete if information is same as above)

Last Name
First Name
Middle Name
Address
Apt. Number
City
State
Zip
Home Phone
Work/CEL Phone
Date of Birth
Age
Social Security #
Driver License #
Driver License ST
Marital Status Married Single Other
Relationship Spouse Parent Other
 
Payment is due at the time of service. Fee of $25 may be charged if appointment not canceled within 24 hours.
 
INSURANCE INFORMATION (PRESENT CARD TO RECEPTIONIST DURING VISIT)
Name of Insured Primary Insurance
Secondary Insurance
 
 Message  
 

CONSENT FOR MEDICAL CARE AND ASSIGNMENT OF BENEFITS

   I hereby provide consent for all medical care and assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plan to Allen Family Clinic, PA. and Frisco Family Clinic. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure the payment.

Email Address *  
Agreement *  
I AGREE
I DO NOT AGREE
 

* Please print this form and bring it to the office *