Patient Information
Name *
Name
Address *
Address
Home Phone *
Home Phone
Work Phone
Work Phone
Mobile Phone
Mobile Phone
Status *
Number of Children
Emergency Contact
Name *
Name
Home Phone *
Home Phone
Work Phone
Work Phone
Mobile Phone
Mobile Phone
Insurance Information
Insurance Phone Number
Insurance Phone Number
Employer Information
Address
Address
Duties Performed *
Presently Working *
Current Medical History *
Past Medical History
Family History
Attorney Information
Name of Attorney
Name of Attorney
Phone Number
Phone Number
Address
Address
Assignment of Benefits
*
Authorization For The Release of Medical Records
*
Verification of Non-Pregnancy
Date of Last Menstruation
Date of Last Menstruation
Acknowledgement of Testing if Medically Necessary
*
Authorization of Direct Payment From Insurance Company to Restore353
*
Credit Card Information
Credit Card Information Will Be Kept On File. Patient Will Not Be Charged Upon Submitting The Patient Intake Form. Please Read Our 24 Hour Appointment Cancellation Policy And Self-Pay Patient Payment Agreement Below. Thank You.
Name on Card *
Name on Card
Expiration Date *
Expiration Date
24 Hour Appointment Cancellation Policy
*
Self-Pay Patient Payment Agreement
*