Patient Information Sheet Please note: Completion of this form will take 24 hours to process to the office. Patient Name (Full Name)* Email* Primary Phone* Secondary Phone Address* Date of Birth* City* State* Zip* Sex* MF Marital Status* SMDW Employer Name Occupation Would you like to be emailed about events and specials? YesNo RESPONSIBLE PARTY Responsible Party Name Email Home Phone* Secondary Phone Address* Date of Birth* City* State* Zip* Sex* Patient Relationship* Employer Name Occupation PREFERRED PHARMACY Pharmacy Name* Address* Street Address Phone Number* PRIMARY INSURANCE Insured’s Name (Full Name) Insured’s Home Number Insured’s Secondary Number Insured’s Address Insured’s Date of Birth Insured’s City State Zip Insured’s Sex Insurance Company Name Insurance ID# Copay Amount – Ex: 00.00 Insurance Company Address Insurance Company State Insurance Company Zip SECONDARY INSURANCE (OPTIONAL) Insured’s Name (Full Name) Insured’s Home Number – Ex. 512-401-2500 Insured’s Secondary Number Insured’s Address Insured’s Date of Birth Insured’s City State Zip Insured’s Sex Insured’s relationship Insurance Company Name Insurance ID# Copay Amount – Ex: 00.00 Insurance Company Address Insurance Company State Insurance Company Zip Authorization and Acknowledgement I/we hereby state that the above information is true and accurate to the best of my/our knowledge. I/we authorize the above named practice to release any information acquired in the course of my treatment to my insurance company, employer, Physicians, Institutions, or third party payors as required for certain claims filed. I Agree I/we authorize direct payment to be made to the above named practice for any and all medical or surgical services rendered. I understand if any services or change are not covered by my insurance carrier or my eligibility can not be verified, I am responsible for all charges incurred. I Agree FOR MEDICARE PATIENTS: THIS OFFICE ACCEPTS BASIC MEDICARE ASSIGNMENTS. MEDICARE PAYS 80% OF THE AMOUNT THEY APPROVE AFTER YOU HAVE MET YOUR DEDUCTIBLE. YOU ARE RESPONSIBLE FOR YOUR DEDUCTIBLE AND THE REMAINING 20%. IF YOU HAVE A SECONDARY INSURANCE THAT COVERS THE REMAINING 20% PLEASE PROVIDE US WITH THAT INFORMATION. ELECTRONIC AUTHORIZATION Submitting an application through this website constitutes your electronic signature. Any record containing an electronic signature shall be deemed for all purposes to have been “signed” and will constitute an “original” when printed from electronic records established and maintained by Buckingham Facial Plastic Surgery. I Agree First Name* Last Name* By submitting this form I agree to the Terms of Use* Δ