Doctor_______________________ (Person you have appt. with today)

Your SS#_______________________________________

Patient Information

 Name_________________________________________________________________________
                                 First                                    M.                                 Last

                        (    )  Single        (    )  Married       (    )  Divorced      (    )  Widow    (    )  Separated

Birthdate________________________Age________________________Race________________

Your Social Security Number__________-_________-______________

Mailing Address_______________________City________________State________Zip_________

Residence___________________________City________________State________Zip_________

Telephone________________________________ Message Phone#________________________

Your Occupation_________________________________________________________________

Your Employer_______________________________________Phone#______________________

Spouse’s Name______________________________________Date of Birth__________________

Spouse’s Employer__________________________________Soc.Sec.#______-______-________

Parent or Guardian Name (if under age18)_____________________________________________

Employer___________________________Date of Birth_______________SS#________________

Nearest Relative or Friend other than spouse in same area or town

Name________________________(City/State/Zip)___________________Telephone___________

REFERRAL

Doctor or person referring you to this office:____________________________________________

INSURANCE

Primary Insurance Co._________________________ID#______________Group#_____________

Name of Private Care Physician (PCP)________________________________________________

Medicaid Welfare #________________________________________________________________

Person responsible for payment today________________________________________________

I give my permission to release medical information to doctors and insurance companies concerned with my medical care.  I herby authorize payment directly to my physicians for this illness or injury, or the physician’s or surgeon’s benefits otherwise payable to me, but not to exceed my indebtedness to said physician.  I understand I am financially responsible to the physician for charges not covered by this assignment.

NOTE: This office does not extend credit or accept post dated checks for office visits or examinations.  The fee for these services may be paid by CASH, CHECK or CREDIT CARD when rendered.  I also understand that MWC will dismiss a patient from care after missing three consecutive appointments without rescheduling.