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Hearing Doctors of Georgia Date _________________ Patient Information () Mr.
() Mrs.
() Ms.
() Miss
Last Name_______________________
() Dr.
First Name _______________________________
Spouse's Name or Parent's Name(s) _____________________________________________ Street Address ______________________________________________________________ City ___________________________
State _______
Zip Code ___________________
Home Phone ________________ Work Phone _____________ Other _________________ E-mail Address _________________________ Family Doctor ________________________ Sex: () Male () Female
Date of Birth _________________________
Insurance Information Plan Name _________________________________________________________________ Insurance ID Number _____________________ Group Name or Number _______________ Insured Partys: Last Name ___________________ First Name _______________________ Insured's Date of Birth __________________Employer ______________________________ Second Carrier ______________________________________________________________ Insurance ID Number _____________________ Group Name or Number _______________ (please provide receptionist with insurance cards) Who may we thank for referring you to us? __ Friend ______________________
__ Doctor Referral ______________________
(name)
__ Yellow Pages
(Name)
__ Newspaper
__ Other ______________________________
Reason For Visit: __ Dizziness
__Hearing Loss
__Hearing Aids
__Earmolds
__Swim Plugs
__ Other ___________________________________________________________________ Payment is expected at the time of service. I here by assign payment to the undersigned. I understand I am financially responsible for any non-covered services. I also hereby authorize the release of any information needed to process the claims. Signature ____________________________________ (parent or guardian)
Date: ______________ 20______
Patient Record of Disclosures: I wish to be contacted in the following manner (check all that apply): ____Home address and phone
____ Work address and phone
____Email address
____No contact
____ Cellphone
Contacts usually include the following (check those you wish to receive): ____Appointment Reminders ____Newsletters ____Special promotions The Notice of Privacy Practices is available upon request. You may have access to a copy of these practices to retain for your records. This practice has the right to change this Notice at anytime. Patient/Guardian Signature________________________ Date_____________________
On a scale of 1 to 10,1 being the worst and 10 being the best, how would you rate your overall ability to hear?