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706-922-4545

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Patient Information
Today's Date
Please choose two appointment dates in order of preference
MM/DD/YYYY
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Time of Day: Morning Afternoon Either
Primary Orthopaedic Problem:
Primary Care Physician*
Referring Physician*
Appointment Physician*
First/Middle/Last Name/Suffix*
Social Security Number*
123-45-6789
Date of Birth*
01/01/1980
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Sex/Martial Status Male Female Married Single Widowed
Occupation
Employer
School
Home Address*
City, State Zip*
Home Phone*
706-555-1234
Work Phone
706-555-1234
Cell Phone
706-555-1234
Nearest Friend/Relative
Relationship
Home Phone
706-555-1234
Work Phone
706-555-1234
Guarantor Information
Person Responsible
For Bill
First/Last Name/Suffix
Address
City, State Zip
Sex / Race Male Female
Relationship to Patient
Phone
Social Security Number
123-45-6789
Date of Birth
01/01/1980
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Company Name
Company Address
City, State Zip
Company Phone
Occupation
Insurance Information (Primary)
Insurance company name
Name of Insured
First/Last Name/Suffix
Relationship to Patient
Date of Birth
01/01/1980
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Policy/Group Number
Social Security Number
123-45-6789
Insured's Employer
Work Phone
706-555-1234
Insurance Information (Secondary)
Insurance company name
Name of Insured
First/Last Name/Suffix
Relationship to Patient
Date of Birth
01/01/1980
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Policy/Group Number
Social Security Number
123-45-6789
Insured's Employer
Work Phone
706-555-1234
Authorization For Treatment and Financial Agreement By checking this box I agree to the following:
I authorize treatment of the person named and authorize information given to the insurance companies. I agree to pay all charges and interest shown by statements, promptly upon presentation thereof, unless credit arrangements are agreed upon in writing with the clinic.

It is agreed that payment will not be delayed or withheld because of any insurance coverage of the pendency of claims thereon, and that all proceeds of the insurance for services rendered are assigned to Advanced Gynecology Associates of Augusta but without the practice assuming sole responsibility for the collection thereof.