Patient Demographics, Consent to treatment, financial responsibility and insurance information Patient Name * First Name Last Name Age Guardian/Parent Date of Birth MM DD YYYY Place of Birth Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone No Country (###) ### #### Family Members Mother Father Children Age 1 to 5 Children Age 5 to 10 Children Age 15 to 20 Children Age 20 to 25 Other family members living at home Presenting Problem Therapy/Consultation Solutions If you are seeing other professionals regarding this issue or other health problems, please list them below: City Contact Information Person Responsible for Payment Address If address same as patient's enter same address Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Name Employer Position Employer Address Enter Employer Address Here Address 1 Address 2 City State/Province Zip/Postal Code Country Employer Phone No Enter Employer phone number Country (###) ### #### Insurance Company Card Holder ID Phone (###) ### #### Group/Policy No Authorizations for Treatment, Payment, and Third-Part Billing I authorize Dr. Goldwater to provide treatment to Patient /Parent/ Legal Guardian Patient /Parent/ Legal Guardian Date Select Date MM DD YYYY I confirm that I am responsible for payment for the services rendered to me and my dependents Patient /Parent/ Legal Guardian Date Select Date MM DD YYYY I authorize Dr. Goldwater to bill a third party (My Insurance Company or the responsible party) and to give them such personal information they require to process the payment on my behalf. Patient /Parent/ Legal Guardian Date Select Date MM DD YYYY Thank you!
