706 613 6650

New Patient Form

Patient Registration Form

Name
First: Last: Middle Initial:
Address:
Street: Apartment #:
City: State: Zip:
Telephone
Home: Work: Ext:
Cell:
Personal Information
Email Address:
Date of Birth (mm/dd/yyyy):
Marital Status: Single Married Divorced Widowed
Employer: Occupation:
Emergency Contact Information
Name: Relation:
Home Phone: Cell Phone:
Work Phone: Extension:
Spouse/Parent Contact Information
Name:
Employer: Occupation:
Home Phone: Cell Phone:
Work Phone: Extension:
Primary Care Physician
Please enter the name of your primary care physician:
Referring Source
Source:
Name(if applicable):

Consent for Disclosure to Family Members or Personal Representative

I have agreed to let certain individuals participate in discussion and decisions related to my medical care. Therefore, I hereby give my permission to Dr. James Moore, Dr. Cesar Gumucio and their staff to disclose my personal medical and financial information to the following individuals(s). This includes discussion of account information, making of appointments, prescription concerns, etc.

Name: Relationship:
Telephone:
 
Name: Relationship:
Telephone:
 
Name: Relationship:
Telephone:

Conditions for Disclosure (check the item(s) that apply):

The practice may disclose information to the individual(s) only in my presence.

The practice may disclose information to the individual(s) above in discussions in my presence and when I am not physically present, including disclosure by telephone, facsimile or email.

Other:

I understand that this consent is in effect until revoked by me with written notice to the practice. I also understand if I have any questions about the privacy of my health information that I can discuss them with the office staff at any time.

Insurance Information

Primary Insurance Information
Policyholder: DOB:
Policy # or ID #:
Relationship to Patient: Self Spouse Parent
Primary Insurance Company:
Name: Phone:
Address
Street:
City: State: Zip:
Secondary Insurance Information
Policyholder: DOB:
Policy # or ID #:
Relationship to Patient: Self Spouse Parent
Secondary Insurance Company:
Name: Phone:
Address
Street:
City: State: Zip:

Is this workman's compensation? YES NO

From time to time we distribute information on new products, procedures and treatments.
I would be interested in receiving these updates via email.


I certify that all of the above information is correct and that I have read and understand the Patient Financial Responsibility statement.