Patient Information

Please fill out the form below and click "submit".

Patient's First Name: *
Patient's Last Name: *
Patient's Middle Initial: *
Phone (Home): *
Phone (Work): *
Phone (Cell): *
Street Address: *
City, State, Zip: *
Email Address: *
May we contact you via email?: Yes No
Social Security Number: *
Date of Birth: *
Sex: Male Female
Name of Spouse (if applicable):
Preferred language:
Ethnicity:
Race:
Employer: *
Occupation: *
Business Address: *
Family Physician: *
Pharmacy:
City, State of Family Physician: *
Party responsible for payment if other than above:
Relationship:
Nearest Relative/Friend (not living with you): *
Relationship: *
Address: *
Phone: *
NAME OF PARENT (if patient under age 18):
Insurance Information
MEDICARE #:
MEDICAID (T-19)#:
Primary or Medicare Supplement
Name:
Address:
Employer Name & Group Policy#:
ID#:
Policy Holder:
Policy Holder’s Date of Birth:
Secondary
Name:
Address:
Employer Name & Group Policy#:
ID#:
Policy Holder:
Policy Holder’s Date of Birth:
By checking this box, I request that payment of insurance or government benefits be made either to me or on my behalf to Dr. Scott G. Eccarius for any service furnished to me by him. I understand that I am responsible for any amounts not paid by my insurance. I also authorize Dr. Eccarius to release medical records and information about me to determine benefits and procure payment.
Acknowledge: * Yes
PATIENT OR GUARDIAN NAME: *
DATE: *