Registration form

    Patient information

    Is this your legal name?

    Insurance information

    Is this person a patient here?

    Is this person covered by insurance?

    In case of an emergency

    Injury information

    Auto accident only

    Have you filed on your auto policy?

    Have you filed on any other party involved insurance?

    Attorney protect

    Women only

    Are you pregnant or is there any possibility you may be pregnant?

    The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Windows User or insurance company to release any information required to process my claims.