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*

    Marital Status*

    Employer Name

    Occupation

    Would you like to be emailed about events and specials?



    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. 512-982-4067

    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/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.



    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.



    First Name*

    Last Name*

    By submitting this form I agree to the Terms of Use*