If you are a new patient, please complete our on-line patient information form.  This will help make your check-in on the date of your appointment proceed much quicker.  Upon arrival to our office, please inform the receptionist that you have completed your patient information online.  We will ask you to complete the form with signature and SS#'s at that time.

Patient Information Sheet On-Line
Patient Name: Last: First: Middle Initial:
Nickname:
Sex: Marital Status:
Birth Date:  (mm/dd/yyyy) Student: Yes No
SS Number We are not a secure line to the internet. We will ask for your SS# upon your arrival to our office.
Address: 
City: 
State: Zip:
Home Phone: Work Phone:
E-mail:
Patient Employer
Parent/Spouse Name:
Same Address:  Yes No (if different)  
List any other children living at home and their age:

Insurance Information
Please complete the following so we may file your insurance correctly.  We do need to have a photocopy of your insurance card.
Name of Insurance Co.
Name of Policy Holder
Policy Holder Birth Date
Policy Holder SS Number We are not a secure line to the internet. We will ask for your SS# upon your arrival to our office.
Policy Holder Employer
Is this family coverage? Yes No  Self Only
Emergency Contact   Someone not listed above
Name  Phone:
Address
Patient Drug Allergies, if any

     

All Charges are due at the time of services.  All professional services rendered are charged to the patient.  Necessary form will be completed to expedite insurance carrier payment, however, the patient is responsible for all fees, regardless of insurance coverage.

     

I hereby authorize the Columbus Medical Center, P.C. to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to the physician (s) all payments for medical services rendered to myself or my dependents.  I understand that I am responsible for any amount not covered by insurance.

Disclaimer
Copyright © 2003 Columbus Medical Center. All rights reserved.