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About Me
Schedule Appointment
FAQs
Gallery
Home
Contact
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Patient Information Form
Patient name:
*
First Name
Last Name
Today's date:
*
MM
DD
YYYY
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email:
*
Home/cell phone:
*
(###)
###
####
Work phone:
(###)
###
####
Sex:
*
Please note: Insurance requires us to enter either male or female for sex. If your gender is different than those listed, please tell us during your appointment so we can update our internal records.
Select
Female
Male
Age:
*
Birth date:
*
MM
DD
YYYY
Relationship status:
*
Single
Married
Partner
Widowed
Separated
Divorced
Significant other
Spouse/partner/significant other's name:
Emergency contact name and relationship:
*
Emergency contact phone(s):
*
(###)
###
####
Your occupation and employer:
Who is responsible for this account for billing purposes?
*
Relationship to patient:
*
Subscriber's employer, work address and phone number:
Primary insurance:
*
Insurance ID:
*
If you do not have insurance, enter n/a
Group #:
*
If you do not have insurance, enter n/a
Secondary insurance:
Subscriber's name:
Subscriber's birth date:
MM
DD
YYYY
Relationship to patient:
Secondary insurance ID:
Secondary group #:
Assignment & Release
*
Check below to accept.
I, the undersigned, certify that I (or my dependent(s)) have insurance coverage as listed above and assign directly to Radiant Sun Acupuncture all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature section on all insurance submissions.
Authorized party signature:
*
Please type full name. You also may print and sign this form if you prefer.
Relationship to patient:
*
Today's date:
*
MM
DD
YYYY
What is the best way to reach you?
choose
Email
Cell phone
Home phone
Work phone
Text
How did you hear about us?
choose
Search engine
Word of mouth
Social media
Ad
Referral
Other (please specify below)
If you heard of us by word of mouth or by a referral, to who can we thank, with your permission?
Or, of you chose "other" above, please enter that information here.
Thank you! Your Patient Information Form has been submitted!
