Piedmont Obstetrics and Gynecology

REGISTRATION FORM

(PLEASE PRINT)

Today’s Date:        

PATIENT INFORMATION
Patients Name:

 Last:

 First:

  Middle:  Marital Status:  □ Single  □ Married     

□ Divorced   □ Separated   □ Widowed
Patients other names:

Husbands Name (if married):

  Date of Birth:                                      Age: 
Address: Social Security #
City: State: Zip Code: Home Phone: (         ) 

Cell Phone : (          ) 

Employer or Name of School if Student: Work Phone :  (         )

School Phone: (         )
Referred by:  □ Another Physician       □ Family       □ Another patient in practice     □ Yellow pages       □ Other
Name of person referring you: Family Doctor:
Nearest Relative or Friend:  Phone Number of Friend/Relative:
Drug Allergies:

 

 

 

INSURANCE COMPANY _______________________________

(PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)
Name of person with primary insurance: Name of person with secondary insurance:
Date of Birth: SS# Date of Birth: SS#
Insured's Employer: Insured's Employer:
Employer Phone #: Employer Phone #:
Relationship of insurance holder to patient:

 □ Self     □ Spouse    □ Parent   □ Step Parent

Relationship of insurance holder to patient:

 □ Self     □ Spouse    □ Parent   □ Step Parent     
 

 

 

 

 

authorization and assignment

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance that my insurance does not cover. I also authorize Piedmont OB/GYN  or insurance company to release any information required to process my claims.

 

 

 

 

 

 

 

Patient/Guardian signature

 

Date

 

 

 

We invite you to discuss frankly with us any questions regarding our services or our fees.  The best medical service is

based on a friendly, mutual understanding between doctor and patient.

 

 

 

 

 

 

 

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