New Patient Form

Most Insurance's Accepted*

First name

Birthdate

City

SSN

Last name

Address

Zip

Phone

EMPLOYMENT INFORMATION

Employer

Employer address

Occupation

WORK PHONE

Extension

EMERGENCY CONTACT

NAME

CELL PHONE

RELATIONSHIP

ALT PHONE

PHARMACY AND LABS

PREFERRED PHARMACY

PREFERRED LAB

Note: Leave blank if no preference

INSURANCE

PRIMARY INSURANCE

SECONDARY INSURANCE

SUBSCRIBER ID/POLICY NUMBER

NOTE: Please present your insurance card to staff at the front desk.

How did you hear about us ?

FINANCIAL POLICY

Thank you for selecting Obesity Medicine & Metabolic Wellness Center for your healthcare needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy.

Please be advised that payment for all services will be due at the time of services rendered, unless prior arrangements have been made. We accept some forms of insurance. Please discuss your insurance coverage with us. For your convenience, we accept Cash, Checks, Credit cards and HSA cards.

I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney's fees etc.

I have read and understand all of the above and have agreed to these statements.

PRINTED NAME

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