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    Pre-Registration

    Form

    PATIENT DEMOGRAPHICS

    NAME
    NAME
    LAST NAME
    FIRST NAME
    SEX
    ADDRESS
    ADDRESS
    City
    State/Province
    Zip/Postal

    INSURANCE INFORMATION

    Maximum file size: 516MB

    Maximum file size: 516MB

    Maximum file size: 516MB

    PATIENT ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES & CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION

    I acknowledge that I have either received a copy of this office’s NOTICE OF PRIVACY PRACTICES or that this office’s NOTICE OF PRIVACY PRACTICES was made available to receive.

    I consent to the use and disclosure of my personal health information by your office for Health Care as outlined in the NOTICE OF PRIVACY PRACTICES.

    I consent to any examination, and/or care to be rendered to me. I give permission to provide medical treatment and services for myself that are deemed necessary including diagnostic and laboratory testing.

    If you present any insurance information for laboratory test/blood work, the patient will be fully responsible for any bills received by requesting laboratory.