New Patient Intake

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PALATINE WELLNESS AND PAIN

118 W. Northwest Hwy l Palatine, IL 60067 l (O) : 847 - 776 - 9700 l (F) : 847 - 589 - 5252

PATIENT INFORMATION

Name*

Address*

City*

State*

Zip*

Phone*

Type*

Phone

Type

Date of Birth*

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Email

How did you hear about the office

RESPONSIBLE PARTY (If not yourself or you are under 18yo)

Name

Phone

Type

Address

City

State

Zip

EMERGENCY CONTACT INFORMATION

Name*

Phone*

Type*

Relationship *

INSURANCE INFORMATION

Insurance

Member ID Number

Group Number

Insurance Type*

I attest that the information I have given here on this and the following forms is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor and/or office and authorize the office to furnish information regarding my illness to my insurance carrier. I understand that I am responsible for any amount not paid by my insurance company.

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Signature*

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