Weight Loss - Registration & Forms

REGISTRATION RECORD

Please, fill out the form for our records.
Required fields are marked with an asterisk (*).

Name: *		Today's Date:

Sex:

Marital Status:

Single Married Divorced

Widow/Widower

Phone: *		E-mail Address

Patient's Address: *

City: *		State: *		Zip Code: *

Occupation:		Name of Employer:		Business Phone:

Employer's Address:

City:		State:		Zip Code:

Emergency Contact: *		Relationship to Patient:

Home Phone: *		Business Phone:

I hereby authorize Greenbelt Medical Associates to apply for benefits for covered services by Dr. Nicholas Azinge and Associates. I certify that the information I have reported is true and correct to the best of my knowledge. I further authorize the release of any necessary information, including medical information, to process this and related claims. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked either by me or my Health Insurance carrier at any time in writing. I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance on my account for any professional services rendered.

ACCEPT

DECLINE

* Required to submit this form

Please click "Submit" to return the completed form to us, and we will respond as quickly as possible.