Patient Information


Patient Information

Last Name

Middle initial

Your Name (required)

Date of Birth (Required - YYYY-MM-DD)

Marital Status
MaleFemale

Address, City, State

Zip

Home Phone Number

Cell Phone Number

Social Security Number:

Age

Race

Preferred Language

___________________________
Patient's Employer

Work Phone

SpousesName

Spouse's Date of Birth

Spouse's Social Security Number

____________________________
In case of Emergency, Notify:

Relationship to Contact:

Emergency Contact Phone:

Your Email (required)


AUTHORIZATION OF RELEASE OF INFORMATION 

I HEREBY AUTHORIZE DRS. WOLFMAN, HODES, ROSENHECK AND GOLDBERG TO RELEASE ANY MEDICAL OR INCIDENTAL INFORMATION THAT MAY BE NECESSARY FOR EITHER MEDICAL CARE OR IN PROCESSING APPLICATIONS FOR FINANCIAL BENEFITS.

CANCELLATION POLICY

AS A COURTESY, AND IN ORDER TO ACCOMMODATE ALL OF OUR PATIENTS, WE ASK THAT YOU GIVE 24 HOURS NOTICE FOR CANCELLATION OR RE-SCHEDULING OF AN OFFICE APPOINTMENT. A $25.00 FEE WILL BE CHARGED FOR FAILURE TO COMPLY WITH THIS REQUEST. FOR PROCEDURES A $25.00 FEE WILL BE CHARGED FOR RE-SCHEDULING.  ADDITIONALLY PROCEDURES THAT ARE RE-SCHEDULED WILL INCUR A $25.00 FEE.

AN ELECTRONIC COPY OF THESE ASSIGNMENTS SHALL BE VALID AS THE ORIGINAL