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  New Patient Form
 
 

ATTENTION:
This form below is only for NEW PATIENTS or for patients that do NOT have a Digital Office username and password login.

If you know your Digital Office login, please LOGIN now to access your information.

If you would like to download a printable version of this form, please go to our Document Center to access our printable forms.

New Patient Information
       
First Name: Last Name:
       
Birth Date: (ex:mm/dd/yr) Social Security#
       
Driver's License # Marital Status:
       
Mailing Address:    
       
City: Zipcode:
       
Home Phone: Work Phone:
       
Cell Phone: Occupation:
       
Employer:    
       
Patient's Spouse Information
       
First Name: Last Name:
       
Birth Date: (ex:mm/dd/yr) Social Security#
       
Work Phone: Cell Phone:
       
Occupation: Employer:
       
Emergency Contact Information

Please provide emergency contact information, other than your spouse.
       
Relationship: Phone:
       
Address:    
       
Insurance and Billing Information
       
Medicare ID: Medicaid ID:
       
Primary Coverage:    
       
Company Insurance: Effective Date:
       
Subscriber's Name: Subscriber's DOB:
       
Group ID: Relationship to Subscriber:
       
Secondary Coverage (optional)    
       
Company Insurance: Effective Date:
       
Subscriber's Name: Subscriber's DOB:
       
Group ID: Relationship to Subscriber:
       
Assignment of Insurance Benefits
 
By checking the box below; I hereby authorize direct payment of medical/surgical benefits to Beaver Family Clinic for services rendered by the physicians, physician assistants, and other medical personnel. I understand that I am financially responsible for any balance not covered by my insurance.
 
 
Authorization to Release Information
 

By checking the box below; I hereby authorize Beaver Family Clinic to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. I further authorize release of all medical records to other physicians that may be taking care of me for referrals, surgery, etc.

I certify that the information I have provided is true and correct.
A PHOTOCOPY OF THESE ASSIGNMENTS SHALL BE VALID AS THE ORIGINAL.

I hereby give Beaver Family Clinic and its physicians, my consent for any necessary medical evaluation and treatment.

   
Patient's Name:
   
Parent/Guardian's Name:
   
Dated:
 
 
 
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  Information on this website is provided for informational purposes only and is not intended as a substitute for the advice provided by your physician of other healthcare professional. You should not use the information on this website for diagnosing or treating a health problem or disease, or prescribing any medication or other treatment.