THEZ07 Patient Information

Primary Care Provider/Medical Information
Name of Primary Care Provider:

First NameLast Name
Phone Number of Primary Care Provider:
Please enter a valid phone number.
Clients that provide us with permission to contact their primary care provider will have a brief letter sent to heir provider indicating that contact has been made at our office. Diagnosis information may also be released to the physician. Do we have your permission to contact your physician? By clicking yes and signing below, you are indicating you give us permission to inform your doctor of your mental health.

YesNo
I verify that the above information is factual and true to the best of my knowledge. Iauthorize the doctor to emloy X-Rays, photographs, anesthetics, medicines, surgeries and other quipment or aids as he/she deems necessary in order to provider the proper patient care. I understand that payment, proof of insurance and/or copay is due at the time of service.

I authorize this office to apply benefits on my behalf for the covered services rendered. Icertify that the insurance information I have provided is factual and correct.
Digital Signature Authorization*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Date*

MonthDayYear
Date
Office use only:

Date Patient First Seen:

Staff Inital:
Should be Empty: