PATIENT REGISTRATION

Oak Cliff Orthopaedic Associates
810 N. Zang Blvd.
Dallas, Texas 75208
214-941-4243

PATIENT REGISTRATION

Referred By:

Other Family Members Seen in Our Office:

Drug Allergies (Please List):

Last Name*: First Name*: Middle:

Social Security Number*: Date of Birth*: Age:

Driver License No.: State:

Address (Permanent): Street: Apt#:

City: State: Zip:

Home Phone: Sex: Marital Status: Number of Dependents:

Employed By: Employer's Address:

Occupation: Bus Phone:

Spouse's Name: Employed By:

Employer's Address: Bus Phone:

Spouse's Occupation:

Patient's Temporary Address:

Nearest Friend or Relative for Emergencies:

Relationship to Patient: Phone:

SIGNATURE OF PATIENT OR LEGAL GUARDIAN:

Responsible Party: If Patient Not Responsible For The Bill, Please Indicate who is Responsible For The Bill:

Name: Relationship to Patient:

Home Phone: Address:

City: State: Zip:

Occupation: Employer:

Employer's Address:

City: State: Zip: Bus Phone:

Responsible Party's Social Security Number:

Driver's License#: State:

Please Indicate Method of Payment For Today's Visit: CheckCash: other

Other (Specify Participating Insurance Plan List):

Request for payment of medical services and laboratory tests at our office will be made at the time of your visit. By asking you to do this, we can cut down the cost of billing, bookkeeping; and hopefully, keep your medical fees down.

I understand that I am responsible for payment of all charges incurred on behalf of myself and my family regardless of insurance benefits.: I Agree I Don't Agree

Date: Responsible Party Signature:

NO PATIENT CAN BE SEEN UNTIL THIS FORM IS COMPLETED IN ITS ENTIRETY

Name & Location of Pharmacy: Name:

Address: Phone: