PATIENT INFORMATION
Social Security # A value is required.	Title A value is required.	Last Name A value is required.	First Name A value is required.	MI A value is required.

Address A value is required.	City A value is required.	State A value is required.	Zip A value is required.	Home Phone A value is required.

Date of Birth A value is required.	Sex Please select an item.	Race Please select an item.	Status Please select an item.	Cell Phone A value is required.

Primary Doctor A value is required.	Employment Please select an item.	Student Please select an item.	Relation to Insured Please select an item.	Occupation A value is required.

Employer/School
Name A value is required. Address A value is required.	City A value is required.	State A value is required.	Zip A value is required.	Business Phone A value is required.
INSURANCE HOLDER
( Do not leave blank unless paying in cash )
Last Name A value is required.	First Name A value is required.	MI A value is required.	Social Security # A value is required.	Date of Birth A value is required.

Address A value is required.	City A value is required.	State A value is required.	Zip A value is required.	Home Phone A value is required.

Occupation A value is required.

Employer/School
Name A value is required. Address A value is required.	City A value is required.	State A value is required.	Zip A value is required.	Business Phone A value is required.

INSURANCE COMPANY
Primary Ins. Co A value is required.	ID # A value is required.	Group # A value is required.	Insured's Name A value is required.

Secondary Ins. Co A value is required.	ID # A value is required.	Group # A value is required.	Insured's Name A value is required.

EMERGENCY CONTACTS
Name A value is required.	Address A value is required.	Relation to Patient A value is required.	Phone A value is required.

Name A value is required.	Address A value is required.	Relation to Patient A value is required.	Phone A value is required.

Name A value is required.	Address A value is required.	Relation to Patient A value is required.	Phone A value is required.

OTHER PERSONAL INFORMATION
Medications Currently Taking A value is required.			Drug Allergies A value is required.

Current Conditions (diabetes, High Blood Pressure, Pregnant, AIDS/HIV, Exposure to STD, etc.) A value is required.

Referred By A value is required.

I authorize the release of any medical information necessary to process health insurance claims. I request payment of the benefits to be made directly to Kenneth E. Robinson, M.D. If surgery is indicated, the portion of fees not covered by the insurance company is due before the planned surgery. Any unexpected balance left after insurance payment has been received will be due in full within 45 days of notification. I further understand that any sums due me if less than $100.00 will be credited to my medical account. I understand there is a $25 missed appointment fee unless I call the office to cancel 24 hours before my appointment time. I further agree to have any issue of medical malpractice decided by neutral arbitration rather than by jury or court trial. This authorization is valid unless rescinded in writing. A photocopy is as valid as the original. Note: There is a fee for all medical forms filled out by this office. Medicare patients: I agree to pay for services not approved by Medicare. Insurance claims will be submitted electronically. I understand that there is a different cancellation policy for surgical procedures, laser, and weight management which will be given to me when necessary. I have read, understand, and agree to all of the above and have given truthful information to the best of my knowledge.