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Gather Demographics

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Required fields are marked with *.

Last Name, First Name, Middle Initial *
Social Security Number
Date of Birth *
Physical Address = House number, Street number, Apt., City, State, Zip code
Mailing Address
Phone Number w/Area Code *
Work Phone Number
Cell Phone Number
Name of Primary Insurance Co.
Phone number of Primary Insurance
Subscriber Name, date of birth and ID number
PCP prior authorization needed? Yes/No (IE: other PCP)
Purpose of Visit
Physician/Date/Time of Appointment to be determined and entered.
Appointment must reflect new or established patient

Inform Patient to bring insurance card, drivers license and any copays that are due at the time of service, and to arrive 15 minutes prior to appointment time to complete paperwork.

Inform self pay patients that payment is expected at time of service.