Patient Form 1

    Legend
    1. First Name (*)
    2. M Initial
    3. Last Name (*)
    4. Email (*)
    5. Sex (*)
    6. DOB (*)
    7. How did you hear about Infini?
    8. Home Phone (*)
    9. Cell Phone (*)
    10. Preferred Phone
    11. SSN
    Home Address
    1. Home Address
    2. City
    3. State
    4. Zip
    Mail Address
    1. Mail Address
    2. City
    3. State
    4. Zip
    Emergency Contact
    1. Name
    2. Phone (*)
    3. Address
    4. City
    5. State
    6. Zip
    Authorization

    Due to the new HIPAA laws that are now in effect, we must have your written authorization
    to release your medical information to a person other then yourself. Understand that your
    information may need to be discussed with your current physician or any other member of
    your physician’s office and/or other medical facility in regards to the scheduling of
    procedures. Only the information needed to do this will be released. This release will be
    valid for one year from the date of signing.

    Whon may we release your medical information to:

    1. Spouce
    2. Sibling
    3. Parent
    4. Son/Daughter
    5. Physician
    6. Attorney
    7. Other
    1. May we send you any correspondence through the mail?
    1. May we leave a message on your answering machine confirming appointment or
      following up on any procedures done in our office that you need to call us about?
    Signature