Patient Registration Form

Dr. Beer Dr. Butler Dr. Chafik Dr. Jain Dr. Siegel

Patient Information

Last Name

First Name

Middle Name

Mailing Address

City

State

ZIP

Physical Address

Home Phone

Work Phone

Mobile Phone

Date of Birth

Social Security Number

Marital Status

S M D W

Spouse's Name

Patient Employer

Employer Address

Emergency Contact

Name

Phone

Relationship

Subscriber Information

Last Name		First Name
Date of Birth		Social Security Number

Is this visit a result of a work injury? Yes No

If yes, date injured

Industrial claim #

Is this visit a result of a car accident? Yes No

If yes, accident date

Attorney Name

PRIVACY NOTICE

Southwest Shoulder Elbow & Hand Center, P.C. and each member of our staff strongly believe in protecting the confidentiality and security of information we collect about you. Your personal information will only be used to communicate with your other physician(s) or to help procure appropriate payment from your insurance company. By signing below, I acknowledgeable a complete Notice of Privacy Policy has been made available to me.
I acknowledge it is my responsibility to notify Southwest Shoulder Elbow & Hand Center, P.C. of changes to any of my insurance(s) including additions, terminations and/or enrollment at the time the event occurs. Otherwise, I understand I may be responsible for any charges occurred during this time.

ALL INFORMATION THAT I HAVE PROVIDED IS CURRENT AND CORRECT

Signed: ________________________________________ Date: ___________________

SUBMIT FORM USING BUTTON BELOW, DO NOT PRINT