Patient Form 1

1. First Name (*)

2. M Initial

3. Last Name (*)

4. Email (*)

5. Sex (*)FemaleMale

6. DOB (*)

7. How did you hear about Infini?

8. Home Phone (*)

9. Cell Phone (*)

10. Preferred Phone

11. SSN

1. Home Address

2. City

3. State

4. Zip

1. Mail Address

2. City

3. State

4. Zip

1. Name

2. Phone (*)

3. Address

4. City

5. State

6. Zip

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? yesno

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? yesno