Patient Form Registry

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
May we mail to the above address?
- Yes
- No
If no, please indicate location to mail to below:
Street Address City State / Province / Region ZIP / Postal Code
Birth Date
Date Format: MM slash DD slash YYYY
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
Date Format: MM slash DD slash 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
Date Format: MM slash DD slash 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
Date Format: MM slash DD slash YYYY
Parent/Guardian's Signature (If under 18 years)
Date
Date Format: MM slash DD slash 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.

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Comments
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