New Patient Form

What is your RACIAL background? *
What is your ETHNIC background? *
What is your language of choice ? *
Upload Your Signature Below Your signature below indicates your consent for the treatment of/as patient and the release of medical information to your insurance company for claim purposes. I understand/acknowledge that any service charges which are deemed medically unnecessary or inappropriate by my insurance company will be paid directly by me.
Your Signature Image format
Date

I have reviewed this practice's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
Patient’s Signature or Personal Representative *
Date *
Name of Patient or Personal Representative *
Personal Representative Relationship to Patient *