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Bi-County Pediatrics, P.C. PATIENT INFORMATION LAST NAME_________________________________ FIRST_____________________________ M.I.______ ADDRESS________________________________________________________________________________ NUMBER STREET CITY STATE ZIP HOME PHONE____________________ BIRTH DATE______________________ SEX________________ SOCIAL SECURITY NUMBER___________________ REFERRED BY _____________________________ GUARANTOR INFORMATION MOTHER LAST NAME____________________________________ FIRST_________________________MI__ ADDRESS ______________________________________ ________________________________________________ SS# _______-____-________ BIRTH DATE__________ MARITAL STATUS________ HOME PHONE_______ EMPLOYER:____________________________________ ADDRESS______________________________________ CITY,STATE,ZIP________________________________ WORK PHONE___________________ CELL PHONE____________________ EMAIL__________________________ EMERGENCY CONTACT: (please give name and number) Name_____________________________________________ Telephone #_______________________________________ Relationship________________________________________ FATHER LAST NAME____________________________________ FIRST_________________________MI__ ADDRESS ______________________________________ ________________________________________________ SS# _______-____-________ BIRTH DATE__________ MARITAL STATUS________ HOME PHONE_______ EMPLOYER:____________________________________ ADDRESS______________________________________ CITY,STATE,ZIP________________________________ WORK PHONE___________________ CELL PHONE____________________ EMAIL__________________________ EMERGENCY CONTACT: (please give name and number) Name_____________________________________________ Telephone #_______________________________________ Relationship_______________________________________ INSURANCE INFORMATION PRIMARY INSURANCE: SECONDARY INSURANCE: _______________________________________________ ________________________________________________ ADDRESS______________________________________ ADDRESS_______________________________________ CITY, STATE, ZIP_______________________________ CITY, STATE, ZIP________________________________ POLICY HOLDER______________________________ POLICY HOLDER_______________________________ DATE OF BIRTH________________________________ DATE OF BIRTH ________________________________ RELATIONSHIP TO PATIENT____________________ RELATIONSHIP TO PATIENT_____________________ POLICY #______________________________________ POLICY #_______________________________________ GROUP #______________________________________ GROUP #________________________________________ PLEASE READ: All professional services are the responsibility of the Guarantor of the patient. Payment is required at the time of each visit. You are responsible for all fees, regardless of insurance coverage. Insurance information must be current. Any charges not paid for by insurance will be the responsibility of the Guarantor. All office policies have been explained to me and I understand that all fees are my responsibility. x________________________________ _____________________________________________ Guarantor Date |
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