Hemet – New patient registration

NAME *

First

Middle

Last

DOB *

date of birth

SEX *

EMAIL *

For Appointment Reminder & Healthcare Information

ADDRESS *

Address Line 1

Address Line 2

City

State

Zip Code

PRIMARY PHONE NUMBER *

main number to contact you such as a cell phone

I AUTHORIZE LAS PALMAS MEDICAL GROUP *

I AUTHORIZE LAS PALMAS MEDICAL GROUP TO LEAVE MESSAGES IN REGARDS TO MY APPOINTMENTS AT THE ABOVE PHONE NUMBER

IN CASE OF AN EMERGENCY, NOTIFY: *

First

Last

EMERGENCY CONTACT PHONE NUMBER *

Relationship of emergency contact *

Emergency contact address

Address Line 1

Address Line 2

City

State

Zip Code

INTERPRETER NEEDED? *

Was advance directive offered *

HOW DID YOU HEAR ABOUT US?

CONSENT FOR TREATMENT -ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE MEDICAL RECORDS *

-I hereby consent and authorize the administration of all emergency diagnostic and therapeutic treatment for me or my minor child that may be necessary in the judgement of the attending physician. I hereby authorize the above named Medical Group and Laboratory to furnish information concerning this illness and I authorize and instruct these same insurance carriers to make payment directly to the above mentioned Medical Group and Laboratory for medical expense benefits (Inc, major medical benefits) otherwise payable to me. A photostatic copy of this assignment and authorization shall be considered as effective and valid as the original. This lien is irrevocable. I also understand that I'm financially responsible to the above named Medical Group and Laboratory for charges not covered and paid by the insurance carrier.

Date: *

Signature *