Patient Demographic Form

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Address

Emergency Contact

Insurance Information

Address of Company
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Permission is hereby granted to healthcare providers within this practice for testing, examinations, treatment, and procedures as deemed necessary, during the course of my care, including HIV testing in the event of body fluid exposure. Information necessary to substantiate my insurance claims may be released by this provider. I authorize payment directly to the provider’s office of all insurance benefits otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether, or not paid by my insurance, for all services rendered on my behalf or on my dependents.

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