New Patient Registration Form
Please print out, complete, and bring to office or Fax to 770-386-4220
We hope to eventually use this feature to cut down on waiting room time!
Patient's Name:_____________________________________________
Home Address:__________________________________________________________________
City: ____________________________ State:_______________ Zip_____________
Telephone(s): (home) __________________________ (work)______________________________________
(cell)_____________________________ (pager)_______________________
Allergies: _________________________________________
Birthdate: _________________ Social Security #:_____________________________
Occupation:_________________________________ Employer:_________________________________________
E-Mail Address:_______________________________________________________________
Husband/Significant Other's Name:__________________________________________________________________
Husband/Significant Other’s Birthdate: _________________
Social Security#___________________________
Address (if different from yours):_____________________________________________________
Husband/Significant Other's Occupation:__________________________________ Employer:_______________________________
Whom May We Thank for Referring You?: ____________________________________________________
Patient's Insurance Carrier:______________________________________________
Secondary Insurance Carrier:____________________________________________
Phone:_________________________________
ID#:___________________________________
Group#:___________________________________Subscriber:________________________________
Please check the name of the provider you wish to see:
□ Fareed Z. Kadum, M.D.
□ Hugo D. Ribot Jr., M.D.
□ Steveq Kang, M.D.
□ E. Jean Day, C.N.M.
□ Cynthia S. Wallace, C.N.M.
□ Macie L. Self, C.N.M.
Authorizations: I authorize the undersigned physicians to release any information in the course of my examination or treatment to my insurance company. I further authorize any benefits due for services rendered to be paid directly to Fareed Z. Kadum, MD, Hugo D. Ribot Jr., MD, Steveq Kang, M.D., E. Jean Day, CNM, Cynthia S. Wallace, C.N.M., or Macie Self, CNM. I understand that if the physician’s fees DO NOT meet my insurance carriers customary and reasonable fee, I will, therefore, be responsible for any balance due after insurance payments. I also understand that payment MUST BE MADE TODAY for services rendered. Please have driver’s license and insurance card ready for photocopy.
Signature:__________________________________________________________Date:______________________