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Phone 512.401.2500 | Fax 512.401.2501
2745 Bee Caves Road, Suite 101 Austin, Texas 78746 | Map It

Patient Information Sheet

Please note: Completion of this form will take 24 hours to process to the office.

PATIENT INFORMATION
*Patient Name (Full Name) *Primary Phone Secondary Phone
*Address *Date of Birth Ex: 1/18/1984
*City, *State, *Zip
*Sex
M F  		Marital Status
S M D W 
Employer Name Occupation  
*WOULD YOU LIKE TO BE EMAILED ABOUT UPCOMING
EVENTS/ SPECIALS? Y N 
*EMAIL ADDRESS:
RESPONSIBLE PARTY NAME   SELF - Fills in Information from Above
*Responsible Party name *Home Phone Ex: 512-401-2500
 Secondary Phone
*Address *Date of Birth 
*City, *State, *Zip
*Sex M F  *Patient's Relationship
Employer Name Occupation  
PRIMARY INSURANCE
Insured's Name (Full Name) Insured's Home Number Ex: 512-401-2500 Insured's Secondary Number
Insured's Address Insured's Date of Birth 
Ex: 1/18/1984
Insured's City, State, Zip
Insured's sex
M F 		  
Insurance Company Name Insurance ID# Copay Amount Ex: 00.00
Insurance Company Address Insurance Company State Insurance Company Zip
SECONDARY INSURANCE (OPTIONAL)
Insured's Name (Full Name) Insured's Home Number Insured's Secondary Number
Insured's Address Insured's Date of Birth  
Insured's City, State, Zip
Insured's sex
M F 		 Insured's relationship
Insurance Company Name Insurance ID# Copay Amount Ex: 00.00
Insurance Company Address Insurance Company State Insurance Company Zip

*  Authorization
and Acknowledgement
I/we hereby state that the above information is true and accurate to the best of my/our knowledge. I/we authorize the above named practice to release any information acquired in the course of my treatment to my insurance company, employer,
Physicians, Institutions, or third party payors as required for certain claims filed.

*  I/we authorize direct payment to be made to the above named practice for any and all medical or surgical services rendered.
I understand if any services or change are not covered by my insurance carrier or my eligibility can not be verified, I am responsible for all charges incurred.

FOR MEDICARE PATIENTS: THIS OFFICE ACCEPTS BASIC MEDICARE ASSIGNMENTS. MEDICARE
PAYS 80% OF THE AMOUNT THEY APPROVE AFTER YOU HAVE MET YOUR DEDUCTIBLE. YOU ARE
RESPONSIBLE FOR YOUR DEDUCTIBLE AND THE REMAINING 20%. IF YOU HAVE A SECONDARY INSURANCE
THAT COVERS THE REMAINING 20% PLEASE PROVIDE US WITH THAT INFORMATION.

*  Submitting an application through this website constitutes your electronic signature. Any record containing an electronic signature shall be deemed for all purposes to have been "signed" and will constitute an "original" when printed from electronic records established and maintained by Buckingham Facial Plastic Surgery.

ELECTRONIC AUTHORIZATION
*First Name *Last Name

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