Patient Information Form

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  • PATIENT FORM

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Person responsible for payment
    First NameLast NameSelf 
  • Insurance Information

  • Name of Insurance:Policy#:Group Name:Group #:Patient Relation to Card Holder:N/A 
  • Name of Insurance:Policy #:Group Name:Group #:Patient Relation to Card Holder: 
  • NamePhone Number 
  • I give authorization to the following person(s) to discuss my medical care, appointments, and billing account information with any staff member of Health Services of North Texas. You may use the same person listed as your emergency contact.
    Name of Person(s) AuthorizedRelationship to Patient 
  • Pediatric Details

    For children under the age of 3
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Emergency Contact

  • NameRelation to PatientPhone Number 
  • I authorize this Release to be kept on file at the clinic and that it can be cancelled, revoked or have changes in authorized person(s) at any time by my written request.

  • Please type in your full name
  • Date Format: MM slash DD slash YYYY