New Patient Information sheet
New Patient Information sheet
The fields marked with * are mandatory
Date of birth*
RESPONSIBLE PARTY, SIGNIFICANT “OTHER” OR SPOUSE INFORMATION
INSURANCE INFORMATION
PHARMACY INFORMATION
I hereby assign, transfer and set over to Neuron Medical Corp. all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. A $50.00 cancellation fee will be charged to any and all patients who do not cancel their appointment within 24 hours prior to their scheduled appointments.
Date of completion*