Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sex *

Male

Female

Date of Birth *

MM

DD

YYYY

Marital Status *

Single

Married

Widowed

Divorced

Separated

May we contact you at work? *

Yes

No

Home Phone *

(###)

###

####

Work/Mobile Phone

(###)

###

####

Person Responsible for Account *

First Name

Last Name

Address 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone *

(###)

###

####

Is patient covered by additional insurance? *

Yes

No

Subscriber Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

(If different from patient's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone

(###)

###

####

I, the undersigned, certify that I (or my dependent) have insurance coverage with the company listed above. I assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I hereby authorize the doctor to release all information necessary to secure the payment of benefits, and authorize the use of this signature on all insurance submissions. *

First Name

Last Name

Date *

MM

DD

YYYY

I hereby authorize and give my consent for Comprehensive Care to contact me by text message or email to remind me and/or confirm appointments with this practice. *

First Name

Last Name

Date *

MM

DD

YYYY