Fine Hearing Care PATIENT INFORMATION

 Patient’s Name:                                                                                                           Phone:                                                

Address:                                                              City                            State               Zip                          

Date of Birth:                       Marital Status:                            Male __  Female __ Social Security Number:                             

Patient Employer:                                                                                            Phone:                                                              

Responsible Party:

Name:                                                                                                              Phone:                                                

Address:                                                              City                           State              Zip                   

Relationship to Patient:                                       Date of Birth:                           Social Security Number:                              

Insurance Information:

Name of Insured:                                                                                             Date of Birth:                                         

Please be sure to have the receptionist photocopy your insurance card for billing purposes.

Nearest Relative (not living in same home):                                                                 Phone:                                                

Address:                                                              City                           State           Zip                          

Primary/Referring Physician:                                                                                       Phone:                                                

Address:                                                              City                            State           Zip                         

Which of the following resources referred you to our office?

� Phone Book       � Newspaper          � Friend           � Physician      ÿ  School District         � Other:                      

Have we provided services to anyone else you know?                      Name:                                                             

I AUTHORIZE THE RELEASE OF INFORMATION TO THE APPROPRIATE MEDICAL FACILITIES, PROFESSIONAL AGENCIES, AND INSURANCE COMPANIES AS DEEMED NECESSARY.  I UNDERSTAND THIS IS CONSIDERED A LEGAL DOCUMENT.

                                                                                                                                                                                    Signature                                                                                                                                                               Date

Payment is expected upon services rendered.

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