New Patient Registration

Client Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Contact Name

If different than above.

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone - Primary *

(###)

###

####

Phone - Secondary

(###)

###

####

Appointment reminders may be sent to the email address.

Yes

No

Primary Care Physician *

First Name

Last Name

Physician Phone Number

(###)

###

####

Name of Financial Responsible Party

First Name

Last Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

This email can be used to payment receipts.

Yes

No

Insurance Company Phone Number

(###)

###

####

Policy Holder's Date of Birth

MM

DD

YYYY

Authorizations and Acknowledgements

1) I authorize and direct my insurance carrier to pay directly to The Speech Language Path, LLC any benefits due under my insurance plan and I agree to pay the balance of expenses not paid under this plan.

2) I understand that all co-pays, deductibles and payments for non-covered services are due at the time of service.

3) I authorize The Speech Language Path, LLC to release my insurance company any medical information necessary to process my claims.

4) I have been provided a copy of The Speech Language Path Notice of Privacy Practices.

5) I have been provided with a copy of The Speech Language Path's Attendance Policy.

The Speech Language Path is a teaching facility and we often have undergraduate and graduate students in the clinic to observe therapy sessions. Allowing observation is completely optional.

I grant permission for students in speech-language pathology to observe my/my child's therapy sessions.

I prefer that students do not observe my/my child's therapy session.

Authorized Signature *

Signature of patient, or responsible party

First Name

Last Name

Date *

MM

DD

YYYY