New Patient Form Patient Information as ofDate(Required)First Name(Required)Middle Name(Required)Last Name(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone(Required)Email(Required) Any restrictions for contacting you? No Yes May we leave you a detailed voicemail? Yes No Contact restrictions:Age(Required)Please enter a number from 0 to 125.Birthdate(Required)Social Security NumberSex Female Male Prefer Not to Disclose Other Marital Status Single Married Widowed Spouse's NameSpouse's Phone #Patient's EmployerOccupationWork PhoneExt.Is it okay to call you at work? Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact (Not in your household)(Required)Relationship to Patient(Required)Home Phone(Required)Cell Phone(Required)Do You Have Health Insurance?(Required) Yes No Primary Insurance(Required)Policy Holder Name(Required) First Middle Last Date of Birth(Required)Secondary InsurancePolicy Holder Name First Middle Last Which Option Applies to You? I am a Self Pay Patient I am a Using Care Credit or Other Financing Options Date of BirthPlease list any person(s) we are permitted to release private health information to regarding your care and/or billing.NameRelationshipPhoneNameRelationshipPhoneI understand that office visit charges are payable on the day service is rendered. I authorize Dr.Your Provider Erin Holloman, MD Ensa Pillow, MD Christian Ponder, DO Christina Hiersche, PA-C Lauren Aduddell, PA-C to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Dr. Erin Holloman, MD Ensa Pillow, MD Christian Ponder, DO Christina Hiersche, PA-C Lauren Aduddell, PA-C and myself.We are happy to file any insurance on your behalf, but please be aware that we DO NOT participate in all plans. If you are uncertain if our office participates in your plan, you should call the customer service number listed on the back of your card and ask them directly. Many companies are now offering multiple plans, and some have a closed network. We are not able to confirm or deny our participation with any certainty. You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account. This includes wireless telephone numbers which could result in charges to you. We may also contact you by sending text messages or e-mails using any e-mail address you provide us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.I have read this disclosure and agree that I may be contacted as described above.Signature(Required)Date(Required)
