Patient Registration Form - Copper Top Foot & Ankle

Date
MM slash DD slash YYYY
Name
SSN
- Male
- Female
Birth Date
MM slash DD slash YYYY
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Untitled
- Minor
- Single
- Married
- Widowed
- Divorced
- Separated
Email
Employer
Work Phone
If a student, name of school and address
Emergency Contact
Phone
Whom may we thank for referring you?
Family Doctor
Responsible Party
Name of person responsible for this account
Relationship to Patient
SSN
Birth date
MM slash DD slash YYYY
Phone
Insurance Information
We will need a copy of your insurance cards before being seen by the physician
List the name of each of your insurance carriers
Information and assignment of benefits
Date
MM slash DD slash YYYY
Signature

I authorize the release of any medical information necessary to process any of my claims. I permit a copy of this authorization to be used in place of the original.
Date
MM slash DD slash YYYY
Signature

I hereby authorize the physicians of this company to apply for benefits on my behalf for covered services rendered by them or by their order. I request that payment from my insurance company be made directly to the physician. I certify that the information I have reported with regard to my insurance coverage is correct. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time.

Responsible Party