PATIENT INFORMATION RECORDS

(Please Print or Write Legibly)

Name  

Address 

 Home Phone No. E-mail address(optional)

Work Phone No.

Place of Employment                                

Driver’s License No.                         Social Security No.

Marital Status Birth Date

Spouse Name Social Security No.

Occupation Work Phone No.

Place of Employment

Religious Preference

             Children:

 NameBirth Date NameBirth Date 

NameBirth Date NameBirth Date

PLEASE LIST A FRIEND OR RELATIVE (OTHER THAN SOMEONE AT YOUR ADDRESS) WHO CAN BE

REACHED IN CASE OF AN EMERGENCY.

Name Relation to Patient

Address Phone

Employer

Employer Telephone No.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF INSURANCE:

PRIMARY INSURANCE:

Insurance Company

Address for Claim

Policy No. Group No. Other

SECONDARY INSURANCE:

Insurance Company

Address for Claim

Policy No. Group No. Other

I hereby assign my insurance benefits under the above plan to Dr. Harris, Puyau, Thomas and Estes. I understand

that I am financially responsible for any charges not covered by this assignment. I will be responsible for any/all

charges that are not considered to be a covered benefit under my health insurance plan. I also hereby authorize the

release of information requested in the course of my examination as needed.

SIGNED ______________________________________________________________________

DATE ________________

PAYMENT METHOD

Visa/Mastercard/AMEX Cash                                      Check (Approved by Checkfax)

ALL FEES MUST BE PAID AT THE TIME OF SERVICE

FIRST (M) LAST

(STREET)

(CITY) (STATE) (ZIP)

781 Colonial Drive                           Office: (225) 201-0505         Renée S. Harris, M.D. • Susan F. Puyau,M.D.               Date __________________

Baton Rouge, LA 70806                   Fax: (225) 201-9955             Terri Thomas, M.D.  Vineeta Estes , M.D.   

Referred by _____________                                              Colette Blanchard,APRN,MSN

 _mailto:Tina@awhbr.com