Fine Hearing Care INFANT INFORMATION

Patient’s Name:                                                                                                Phone:                                               

Nickname:                               Male _____ Female _____ Social Security Number:                         

Address:                                                              City                                             State        Zip                     

Date of Birth:                                       Age:                             Grade:__________

Mother’s Name:                                                                       Occupation:                                        

Father’s Name:                                                                                    Occupation:                                        

Responsible Party:

Name:                                                                                                  Phone:                                               

Address:                                                               City                                           State             Zip                      

Relationship to Patient:                                                            Social Security Number:                                 

Insurance Information:

Name of Insured:                                               Insured’s Date of Birth:                            Insured’s Social Security Number:                               

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      � Other:                                  

Have we seen anyone else in your family? _____ 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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