Mr. Mrs. Miss
Male Female

Date:
Patient's Last Name:  First Name:
Middle Name:  Age:  DOB:
Street Address: Apt.#:
City:  State:  Zip:
Marital Status:   Single Married Widowed Divorced Separated
Home Phone:  Business Phone:  Cell Phone:
SS#:  E-Mail Address:
Patient's Occupation:
Employer's Name & Address:
Person to Notify (Name & phone # of relative or friend not residing with you.)

Primary Care MD:
Pharmacy Name   Pharmacy Phone #:

FINANCIAL RESPONSIBILITY

Last Name:  First Name:
Middle Name:  SS#:
Relationship to Patient:
Address: Apt.#:
City:  State:  Zip:
Home Phone:  Business Phone:
Employer's Name & Address:

INSURANCE - Please present your insurance card to the receptionist.

Name of Insurance Company:
Address:
Policy or Certificate #:  Group #:
Policy Holder's Name:
Policy Holder's DOB:  Effective Date:
Name of Insurance (Additional):
Address:
Policy or Certificate #:  Group #:
Effective Date: Policy Holder's Name:

I consent to treatment necessary for the care of the above named patient.
I authorize the release of all medical records to the referring and family physicians and to my insurance company, if applicable.
I allow fax transmittal of my medical records if necessary.
I acknowledge full financial responsibility for services rendered by Brookwood ENT Asso., P.C.
I understand that payment of charges incurred is due at the time of service unless other definite financial arrangements have been made prior to treatment.
I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges.
I further authorize and request that insurance payment be made directly to Brookwood ENT Assoc., P.C. should they elect to receive such payments.
I have read and fully understand the above consent for treatment, financial responsibility, release of medical information and insurance authorization.