Confidential Patient Form - Encryption Enabled

 
  Thank you for taking the time to visit our web site. This page is provided to collect your information in a secure and compliant manner.  The information you provide will be protected according to federal HIPAA guidelines for your privacy and security. This information may be shared with a third party provider for the purposes of evaluating your specific situation. Please try to fill out as many fields as possible. Be sure to leave a phone number, email, city and state so we can contact you after reviewing your information. We thank you again for taking the time to fill this form.  
     
 

Personal Information

 
     
 
Zip Code*    
First Name*    
Last Name*    
Phone    
Cell Phone    
Best time to call    
Email*    
Address    
City    
State    
County    
 
     
 

Clinical Information

 
     
 
Date of Birth*    
Age    
Height    
Weight     lbs
BMI    
Gender     Male     Female
 
     
 

Other Information

 
     
 
  How did you hear about us?
Patient or person who referred you to our web site?
Profession: 
State how this condition affects your life:
 
 

Insurance Information

 
     
 
Name of Health Insurance Company   
Type of Health Insurance?   
Group Number   
Policy Number              
Will you need financing for your procedure?    Yes  No
 
Please be aware that the information you provide us on this form may be shared with a Third Party healthcare provider in your area. By completing this form you are authorizing us to disclose your individually identifiable health information to a Third Party healthcare provider.