Form Registry Cincinnati Ohio Plastic Surgeon

Patient Form Registry

First Name:

Last Name:

Address:

City:

State:

Zip Code:

May we mail to the above address? Yes No

If no, please indicate location to mail to below:

Address:

City:

State:

Zip Code:

Birth Date:

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Age:

Email address:

May we email you with announcements and specials? Yes No

Phone Number (home):

May we call you at this number? Yes No

Phone Number:

May we call you at this number? Yes No

Cell:

Employer:

Position:

Phone Number:

May we call you at this number? Yes No

Emergency Contact Person:

Phone Number:

(Relationship to Patient)

If you are eligible for any insurance benefits, please have a copy made of your card in addition to the information below. Thank you.

If Insurance will be covering part or all of your expenses, please complete the remainder of the form. Thank you.

If Patient Is Under The Age of 18, We Require Responsible Party DOB & SSN(see Below)

Primary Insurance Insurance Co.

Insurance ID# Group #

Street Address City State Zip

Name Of Person Who Carries Insurance SSN DOB

Patient Relationship To Insured

Insured Employer City/State/Zip

Workers' Compensation: Were You Injured On The Job? Date of Injury (MM/DD/YYYY):

Workers' Compensation Carrier Address City/State/Zip

Were You Injured In An Auto Accident? (Accident Date) (MM/DD/YYYY):

Details related for reason of today's visit

Name:

Date (MM/DD/YYYY):

ALL PROFESSIONAL SERVICES ARE CHARGED TO THE PATIENT. THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL. I HEREBY ASSIGN ALL MEDICAL AND SURGICAL BENEFITS TO INCLUDE MAJOR MEDICAL BENEFITS INCLUDING MEDICARE PRIVATE INSURANCE AND OTHER PLANS TO ALLIED ENT, Inc. I GIVE AUTHORIZATION TO RELEASE ANY INFORMATION TO MY INSURANCE COMPANY THAT IT MAY NEED.

Name:

Date (MM/DD/YYYY):

DISCLOSURE: Dr. Alexander S. Donath has a financial interest in the Surgical Center of Evendale.

Patient's Signature (If 18 years or older)

Date (MM/DD/YYYY):

Parent/Guardian's Signature (If under 18 years)

Date (MM/DD/YYYY):

As confidentiality is a priority with our practice, please indicate any more information which may be useful for our communication to you or anything as it relates to your care. Thank you.

Click here to download Patient Registration Form