Intake Form

Patient Information

Patient Information

In Case of Emergency

Insurance Information

Primary Insurance

Secondary Insurance

Authorization and Benefit Assignment

I hereby authorize the release of any information necessary to file a claim with my insurance company and assign benefits otherwise payable to me, to the doctor or group indicated on the claim.
I understand that I am financially responsible for any service or balance not covered by my insurance carrier and that it is my responsibility to follow all criteria under my insurance plan.