Patient Information

First Name*

Last Name*

Date of Birth (MM/DD/YYYY)*

Address

City

State

Zip Code

Phone*

Email

Sex (Male or Female)*

Marital Status (Married, Single, Divorced, or Widowed)

How did you hear about us? (Doctor, Relative / Friend, Internet, or Other)

Spouse Information

Spouse Name

Spouse Date of Birth (MM/DD/YYYY)

Spouse Phone

Spouse Employer

Insurance Information

Primary Insurance

Insurance Company

Policy / ID Number

Group Number

Insured's Name

Insured's Date of Birth (MM/DD/YYYY)

Relationship to Insured (Self, Child, Spouse, or Other)

Sex (Male or Female)

Secondary Insurance (if applicable)

Insurance Company

Policy / ID Number

Group Number

Insured's Name

Insured's Date of Birth (MM/DD/YYYY)

Relationship to Insured (Self, Child, Spouse, or Other)

Sex (Male or Female)

I hereby assign my insurance benefits to be paid to Heal 360. I understand that I am financially responsible for this bill, regardless of insurance coverage. I also authorize the release of any information required in the processing of insurance claims. I understand that I am responsible for changes not covered or reimbursed by the above

agents. I agree in the in the event of non-payment to assume the cost of interest, collection, and legal action. (If required)

Patient's Signature (type full legal name)*

Please do not submit any Protected Health Information (PHI).

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