Patient's Mailing Address*
Phone Number (Home, Work, Cell)*
Patient's Date of Birth (MM/DD/YYYY)*
Patient's Preferred Language
Responsible Party's Last Name
Responsible Party's First Name
Responsible Party's Middle Initital
Responsible Party's Mailing Address
Phone Number (Home, Work, Cell)
Date of Birth (MM/DD/YYYY)
Responsible Party's Gender
Responsible Party's Marital Status
Responsible Party's Relationship to Patient
Insurance Policy Holder's Subscriber ID#
Insurance Policy Holder's Group#
Insurance Policy Holder's Last Name
Insurance Policy Holder's First Name
Insurance Policy Holder's Middle Initial
Insurance Policy Holder's Date of Birth (MM/DD/YYYY)
Insurance Policy Holder's Gender
Insurance Policy Holder's Marital Status
Insurance Policy Holder's Relationship to Patient
Emergency Contact Full Name*
Emergency Contact Phone #*
Emergency Contact Relationship to Patient*
In case of an emergency, do we have permission to contact the person listed above?*
I certify that the information provided above is completed and accurate to the best of my knowledge*
Signature of Patient/Patient Representative*
CONSENT FOR TREATMENT OF AN ADULT (Printed Name of Client/Legal Representative)*
CONSENT FOR TREATMENT OF AN ADULT (Witness Date)*
CONSENT FOR TREATMENT OF A DEPENDENT (Printed Name of Client/Legal Representative))*
CONSENT FOR TREATMENT OF A DEPENDENT (Witness Date)*