PATIENT INFORMATION SHEET

Patient Information

Patient Name

Referred By

Social Sec.

Date of Birth

Age

Drivers License No.

Gender
Male
Female

Address

City

State

Zip

Phone - Home

Work

Cell

Email Address

Best way to contact you
Home Phone
Work Phone
Cell Phone
Email

Would you like to access portions of your health record on line?
Yes
No

Would you like appointment reminders by email?
Yes
No

Employer

Occupation

Spouse Name

Spouse Employer

Emergency Contact

Phone

Relationship

Insurance Information

Do you have healthcare insurance?
Yes
No

Parents of Minor Children

Mother’s Name

Date of Birth

Father’s Name

Date of Birth

RESPONSIBILITY FOR PAYMENT OF MEDICAL SERVICES

I understand that Triangle ENT & Allergy will file my insurance as a courtesy. However, I am ultimately responsible for all medical fees relating to my care should my insurance deny for reasons such as: authorization, deductible or noncovered service. I understand that I will be responsible for my bill.

I hereby authorize my insurance benefits to be paid directly to Triangle ENT & Allergy. I also authorize Triangle ENT & Allergy to release information acquired in the course of my examination to my insurance company and/or their representatives.

CANCELLATION POLICIES

If you are unable to keep an appointment, please give our office 24 hours notice. This courtesy of cancelling 24 hours in advance will allow another patient the opportunity to use that appointment time. A missed/no show appointment may result in a minimum $25.00 charge to you.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

LuxSci helps ensure HIPAA-compliance for email and web services.