Patient:      S.S.#
                           First Name                  M.I.                 Last Name

  Address:
                   Street                       Apt. #                           City                                   State                         Zip Code

  Birth Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1965 1964 1963 1962 1961 1960 Home Phone:    Email Address:

  Gender: Male Female                      Work Phone:        Occupation:

  Status: Single Married Divorced Domestic Partner



  Primary Insurance Information

       Policy Holder:                  S.S.#

  Insurance Name: Policy Number:

  Birth Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1965 1964 1963 1962 1961 1960     Relationship to Patient: Self Spouse Child

  Secondary Insurance Information

       Policy Holder:                  S.S.#

  Insurance Name: Policy Number:

  Birth Date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1965 1964 1963 1962 1961 1960     Relationship to Patient: Self Spouse Child


     I, the undersigned, have coverage with __________________ and assign directly to Dr. ____________________ all        medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for        al charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to        secure  the payment of benefits. I authorize the use of this signature on all my insurance        submissions____________________________     _____________________            
                           Signature of insured/ Guardian                         Date