Patient Form Registry Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code May we mail to the above address?YesNoIf no, please indicate location to mail to below: Street Address City State / Province / Region ZIP / Postal Code Birth Date AgeEmail address* May we email you with announcements and specials?YesNoPhone Number (home):May we call you at this number?YesNoPhone NumberMay we call you at this number?YesNoCell*EmployerPositionPhone NumberMay we call you at this number?YesNoEmergency 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 ZipName Of Person Who Carries Insurance SSN DOBPatient Relationship To InsuredInsured Employer City/State/ZipWorkers' Compensation: Were You Injured On The Job? Date of Injury (MM/DD/YYYY)Workers' Compensation Carrier Address City/State/ZipWere You Injured In An Auto Accident? (Accident Date) (MM/DD/YYYY)Details related for reason of today's visitName*Date 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 DISCLOSURE: Dr. Alexander S. Donath has a financial interest in the Surgical Center of Evendale.Patient's Signature (If 18 years or older)Date Parent/Guardian's Signature (If under 18 years)Date 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 CAPTCHA* I accept the Terms of Use NameThis field is for validation purposes and should be left unchanged.
