PATIENT'S
LAST
NAME_______________________________FIRST___________________________MI_________SEX______

MAILING ADDRESS________________________________________________________________________
                                                #Street                                                                                    Apt#
                  _______________________________________________________________________________
                  City                                                                       State                                                     Zip
PHONE#___________________________________________CELL PH#_____________________________

BIRTHDATE______________________________AGE_________________SOCIAL SEC #________________

EMPLOYERS NAME___________________________EMPLOYERS PHONE#___________________________

SPOUSE'S NAME___________________________SPOUSE'S SOC SEC#_____________________________

______________________________________________________________________________________
IF PATIENT IS A MINOR, PLEASE FILL OUT THIS SECTION:
RESPONSIBLE PARTY________________________RELATIONSHIP TO PATIENT_______________________
PARENT'S NAME____________________________PARENT'S SOC SEC#____________________________
RESPONSIBLE PARTY'S PHONE#_______________CELL PHONE#__________________________________
RESPONSIBLE PARTY'S EMPLOYER__________________________________________________________
EMPLOYER'S PHONE#_____________________________________________________________________
_______________________________________________________________________________________

OUR POLICY IS PAYMENT AT THE TIME OF SERVICE -
HOW DO YOU PLAN TO PAY FOR YOUR SERVICES TODAY?
     CASH_______________CHECK_______________CREDIT CARD______________ATM_______________
EMERGENCY CONTACT_____________________________________________________________________
                                              Someone not living with you                                                                           Phone#

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PLEASE NOTE: THIS OFFICE DOES NOT BILL THIRD PARTY CLAIMS (MOTOR VEHICLE ACCIDENTS, INJURIES SUSTAINED SHOPPING, HOMEOWNERS LIABILITY CLAIM, ETC.) PAYMENT IS EXPECTED AT THE TIME OF SERVICE AND A BILLING/RECEIPT WILL BE ISSUED FOR YOUR BILLING PURPOSES.

REGARDING WORKERS COMPENSATION CLAIMS-WE REQUIRE PRIOR AUTHORIZATION FROM YOUR EMPLOYER BEFORE YOU CAN BE SEEN FOR YOUR INITIAL OFFICE VISIT.  IF YOUR CLAIM IS DENIED, EVEN THOUGH YOUR EMPLOYER AUTHORIZED THE VISIT, YOU WILL BE HELD FINANCIALLY RESPONSIBLE FOR PAYMENT IN FULL ON YOUR ACCOUNT.

IF A NARCOTIC/PAIN MEDICATION IS PRESCRIBED FOR YOU, WE REQUIRE A COPY OF YOUR DRIVERS LICENSE AND YOUR THUMB PRINT.

PATIENT/PARENT/RESPONSIBLE PARTY SIGNATURE______________________________________________

TREATMENT AUTHORIZATION - I grant permission to the physician and staff as directed by the physician of Hilltop Medical Clinic to perform any medical or surgical treatment and to administer such local anesthetics and/or drugs as may be deemed necessary in the diagnosis and treatment of said patient for today and future office visits.  FOR A CHILD PATIENT -I understand by authorizing treatment I am also accepting responsibility to be the financial party on this and all future office visits for this minor patient until (s)he is legally considered an adult at age 18.

___________________________________________________         ______________________________
Signature of Patient, Parent, Authorized or Legal Guardian                               Signers Social Security #