Baton Rouge Vascular Associates - Patient Registration

Baton Rouge Vascular Associates - Patient Registration

Patients please PRINT this page, fill out the form, and bring it in to the office. Or you may download
and print out this Registration Form as a PDF and fill it out and bring it in. Thank you!

All fields are required (please write N/A for items that are not applicable).

PATIENT	LAST		FIRST		MIDDLE	AGE	MALE
							FEMALE

MAILING ADDRESS	HOME PHONE

CITY		STATE	ZIP	EMPLOYER		OCCUPATION

EMPLOYER'S ADDRESS		CITY		STATE	ZIP	WORK PHONE

DATE OF BIRTH			SS #			MEDICARE #

MARITAL STATUS				SPOUSE'S NAME

EMAIL ADDRESS:

GUARANTOR	RELATIONSHIP	BIRTHDATE

ADDRESS		CITY		STATE	ZIP	HOME PHONE

EMPLOYER	ADDRESS	WORK PHONE

PRIMARY INSURANCE CO.	ADDRESS

POLICY HOLDER NAME	BIRTHDATE	GROUP #

POLICY HOLDER EMPLOYER	ADDRESS

SECONDARY INSURANCE CO.	ADDRESS

POLICY HOLDER NAME	BIRTHDATE	GROUP #

POLICY HOLDER EMPLOYER	ADDRESS

NEAREST RELATIVE (not at same address)

ADDRESS	HOME PHONE

FAMILY DOCTOR	PHONE

CHIEF COMPLAINT

ALLERGIES?	TO WHAT?
YES NO

ARE YOU PRESENTLY UNDER TREATMENT FOR ANY OTHER ILLNESS OR INJURY? (Please Explain)

ARE YOU PREGNANT OR IS THERE ANY CHANCE YOU COULD BE? YES NO

CHIEF COMPLAINT

HOW DID YOU FIND OUT ABOUT Vascular Associates?

To my knowledge the above information is correct. I give my consent for treatment for this illness or injury described herein and I understand that I am financially responsible to Vascular Associatesfor all charges not covered by any and all insurances. If payment is not made at the time services are rendered, adequate provision must be made for payment and additional credit information may be required. I understand that both parents of a minor patient may be asked to sign a statement of financial responsibility and that if a patient is married, under some circumstances, the patient's spouse will be required to sign the statement of financial responsibility. I authorize payment directly to Vascular Associates of any insurance policy benefits payable to me, and I hereby assign all such policy benefits to Vascular Associates.
PATIENT'S SIGNATURE	DATE

SIGNATURE OF ADDITIONAL RESPONSIBLE PARTY	RELATIONSHIP	DATE

Vascular Associates reserves the exclusive right to designate which of its employees shall perform service.

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