..,.._, SOCIATES OF SURGERY Dear New Patient: 4370 Medical Arts Dr STE 200 Flower Mound, Texas 75028 Phone: 972-219-6800 Fax: 972-219-0053 We look forward to seeing you at your upcoming appointment. Please fill out the enclosed paperwork and bring it with you to your appointment and give it to the receptionist when you sign in, along with your insurance card and picture ID. We will make every effort to get all medical records that we need for your visit from your referring Physician. It is very important that those records are here in our office 24 hours prior to your appointment. If we do not receive them we may ask that you call your Physician and request them. If you have any questions, please don't hesitate to call our office. Again, we look forward to seeing you soon, The Staff at Associates of Surgery IF THERE IS PAPERWORK FROM YOUR EMPLOYER/DISABILITY INSURANCE THAT NEEDS TO BE COMPLETED BY OUR MEDICAL STAFF, THE FIRST SET OF PAPER WORK THERE WILL BE A FEE OF$25 A $10.00 FEE WILL BE CHARGED FOR ANY ADDITIONAL PAPERWORK THAT IS NEEDED. IT IS VERY IMPORTANT THAT PAPERWORK BE FILLED OUT COMPLETELY.
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..,.. , SOCIATES OF SURGERY.....,.._, SOCIATES OF SURGERY Dear New Patient: 4370 Medical Arts Dr STE 200 Flower Mound, Texas 75028 Phone: 972-219-6800 Fax: 972-219-0053 We look forward
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..,.._, SOCIATES OF SURGERY
Dear New Patient:
4370 Medical Arts Dr STE 200 Flower Mound, Texas 75028
Phone: 972-219-6800 Fax: 972-219-0053
We look forward to seeing you at your upcoming appointment. Please fill out the enclosed paperwork and bring it with you to your appointment and give it to the receptionist when you sign in, along with your insurance card and picture ID.
We will make every effort to get all medical records that we need for your visit from your referring Physician. It is very important that those records are here in our office 24 hours prior to your appointment. If we do not receive them we may ask that you call your Physician and request them.
If you have any questions, please don't hesitate to call our office.
Again, we look forward to seeing you soon,
The Staff at Associates of Surgery
IF THERE IS PAPERWORK FROM YOUR EMPLOYER/DISABILITY INSURANCE THAT NEEDS TO BE COMPLETED BY OUR MEDICAL STAFF, THE FIRST SET OF PAPER WORK THERE WILL BE A FEE OF$25 A $10.00 FEE WILL BE CHARGED FOR ANY ADDITIONAL PAPERWORK THAT IS NEEDED.
IT IS VERY IMPORTANT THAT PAPERWORK BE FILLED OUT COMPLETELY.
ASSOCIATES OF SURGERY
PATIENT INFORMATION Date:
Last Name First Name Middle Initial DOB
Street Address (include apartment or space number if applicable)
City State Zip Code E-Mail
Home Telephone#: Work# Cell#
Social Security # __________ Male D Female D Marital Status
I irrevocably assign payment of medical benefits to the undersigned physician for services rendered.
M.D.
A photocopy of this assignment is to be considered as valid as the original. I understand I am responsible for all services rendered. I hereby authorize said assignee to release all infonnation necessary to secure payment.
SIGNATURE (PATIENT OR PARENT/GUARDIAN) DATE
ASSOCIATES OF SURGERY *PLEASE ANSWER ALL, IF NONE WRITE NONE OR N/A*
Patient Name DOB
Reason for visit:
PAST MEDICAL HISTORY: (CHECK ALL THAT YOU HAVE HAD IN THE PAST)