Hearing Doctors of Georgia

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Hearing Doctors of Georgia Date _________________ Patient Information () Mr.

() Mrs.

() Ms.

() Miss

Last Name_______________________

() Dr.

First Name _______________________________

Spouse's Name or Parent's Name(s) _____________________________________________ Street Address ______________________________________________________________ City ___________________________

State _______

Zip Code ___________________

Home Phone ________________ Work Phone _____________ Other _________________ E-mail Address _________________________ Family Doctor ________________________ Sex: () Male () Female

Date of Birth _________________________

Insurance Information Plan Name _________________________________________________________________ Insurance ID Number _____________________ Group Name or Number _______________ Insured Partys: Last Name ___________________ First Name _______________________ Insured's Date of Birth __________________Employer ______________________________ Second Carrier ______________________________________________________________ Insurance ID Number _____________________ Group Name or Number _______________ (please provide receptionist with insurance cards) Who may we thank for referring you to us? __ Friend ______________________

__ Doctor Referral ______________________

(name)

__ Yellow Pages

(Name)

__ Newspaper

__ Other ______________________________

Reason For Visit: __ Dizziness

__Hearing Loss

__Hearing Aids

__Earmolds

__Swim Plugs

__ Other ___________________________________________________________________ Payment is expected at the time of service. I here by assign payment to the undersigned. I understand I am financially responsible for any non-covered services. I also hereby authorize the release of any information needed to process the claims. Signature ____________________________________ (parent or guardian)

Date: ______________ 20______

Patient Record of Disclosures: I wish to be contacted in the following manner (check all that apply): ____Home address and phone

____ Work address and phone

____Email address

____No contact

____ Cellphone

Contacts usually include the following (check those you wish to receive): ____Appointment Reminders ____Newsletters ____Special promotions The Notice of Privacy Practices is available upon request. You may have access to a copy of these practices to retain for your records. This practice has the right to change this Notice at anytime. Patient/Guardian Signature________________________ Date_____________________

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