Home » Patient Form 1 Patient Form 1 Legend First Name (*) M Initial Last Name (*) Email (*) Sex (*)FemaleMale DOB (*) How did you hear about Infini? Home Phone (*) Cell Phone (*) Preferred Phone SSN Home Address Home Address City State Zip Mail Address Mail Address City State Zip Emergency Contact Name Phone (*) Address City State 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: Spouce Sibling Parent Son/Daughter Physician Attorney Other May we send you any correspondence through the mail? yesno 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? yesno Signature