New Patient Registration Form (Page 2 of 4) in pdf

New Patient Registration Form Page 2

New Patient Registration Form

Responsible Party Information

Who is financially responsible for the account? (Note: The responsible party can never be a child.)

Is the Responsible Party the same as the patient information? Yes___ No__ (if no, please fill in the

information below)

Name _______________________________________

Address _____________________ City __________ State ___ Zip ____

Phone Number _________________

Email Address _________________________________________

If patient is a MINOR, fill in responsible parent or guardian:

Patient/Guardian Name _________________________

Patient/Guardian Address __________________ City ______ State ____ Zip ____

Patient/Guardian Phone Number ____________

Patient/Guardian Email Address _____________________________

I acknowledge the above information is correct and I accept financial responsibility for any services

offered for my dependent or myself.

Signature __________________________________________

Date __________

2 of 4

SLPG-NewRefFormJan09

New Patient Registration Form Page 2