First Name: [r_PatientFirstName]  Last Name: [r_PatientLastName]   Date of Birth   [r_dobmonth] / [d_dobday] / [d_dobyear] 

SSN:    [r_PatientSS1]                 Marital Status:  [r_MaritalStatus]              Phone #  [r_PatientPhone3]   Cell #  [PatientPhone4]

Spouse/Parent  [Spousename]  Date of Birth   [dobmonthsp] / [d_dobdaysp] / [d_dobyearsp]

Address [r_PatientAddress] City, State [r_PatientCity]   Zip  [PatientZip]  

Mailing Address [PatientAddress2]   City, State [PatientCity2]   Zip  [PatientZip2]  

Email address  [re_PatientsEmailAddress]

Employment Information

Patient’s  [Employer]  Occupation  [Occupation]  Phone  [PatientWorkPhone]

Spouse’s [Employersp] Occupation  [Occupationsp]   Phone  [PatientWorkPhonesp]

Insurance Information

Primary Company [r_HealthInsName1] Other Insurance: [OtherIns1] Policy ID# [InsuranceID1]

First Name: [BillingFirstName1]  Last Name: [BillingLastName1]  Policyholder’s SSN  [BillingSS1]

Policyholder's Birthday: [Resp_month1] / [Resp_day1] / [Resp_year1]        

Secondary Company [HealthInsName2] Other Insurance: [OtherIns2] Policy ID#  [InsuranceID2]

First Name: [BillingFirstName2] Last Name: [BillingLastName2]  Policyholder’s SSN  [BillingSS2]

Policyholder's Birthday:  [Resp_month2] / [Resp_day2] / [Resp_year2]         

Medicare [C7]  [C8]    Medicare Number  [medicare]  Responsible party  [mcareresp]

Important Information PLEASE READ

If you would like your medical information released to anyone (other than yourself) please list their names.

1. [Info_release] 2. [Info_release2]   3. [Info_release3]

Please present all insurance cards & copayments to the receptionist each time you come in to be seen

I understand that all charges (including those not paid by insurance), collection fee, bank/returned check fees, legal fees and failure to keep appointment fees are the financial responsibility of the patient (or the parent/guardian in the case of a minor). I hereby authorize Dr. Schweinshaupt to release all information concerning my illness (es) and treatments to my insurance carriers/health plans. In the event that Dr. Schweinshaupt participates with my insurance carrier/health plan, I hereby assign all available benefits and payments directly to him for medical services rendered. I understand that I am financially responsible for all balances not covered by my insurance carrier/health plan, and authorize Dr. Schweinshaupt to charge my credit card for the full amount of any unpaid balances.  I acknowledge notification of the privacy practice act.

[C3]  I agree

* denotes required field         I give my permission to leave medically related messages on my voicemail   [C9] [C10]