Patient Information Sheet

New Patient Registration Form

PATIENT INFORMATION

PLEASE PRINT CLEARLY

*Patient Name (First, Middle Initial, Last)

*Primary Phone

Secondary Phone

*Address

*Date of Birth

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*Social Security Number

*City,

*State,

*Zip

*Sex
MF

*Marital Status
SMDW

*Employer Name

*Occupation

*WOULD YOU LIKE TO BE EMAILED ABOUT UPCOMING EVENTS/ SPECIALS?YN

*EMAIL ADDRESS:

RESPONSIBLE PARTY NAME

*Responsible Party name

*Home Phone

Secondary Phone

*Address

*Date of Birth

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Social Security Number

*City,

*State,

*Zip

*Sex
MF

*Patient's Relationship

*Employer Name

*Occupation

PRIMARY INSURANCE

*Insured's Name (First, Middle Initial, Last)

*Insured's Home Number

Insured's Secondary Number

*Insured's Address

*Insured's Date of Birth

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*Insured's Social Security #

*Insured's City,

*State,

*Zip

*Insured's sex
MF

*Insurance Company Name

*Insurance ID#

*Copay Amount

*Insurance Company Address

*Insurance Company State

*Insurance Company Zip

SECONDARY INSURANCE

Insured's Name (First, Middle Initial, Last)

Insured's Home Number

Insured's Secondary Number

Insured's Address

Insured's Date of Birth

Open the calendar popup.

Insured's Social Security #

Insured's City,

State,

Zip

Insured's sex
M F

Insured's relationship

Insurance Company Name

Insurance ID#

Copay Amount

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.

AUTHORIZATION ELECTRONICS
*First Name	*Last Name

2008 Austin Texas Facial Plastic Surgery