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Eric Hardoon, V

PATIENT REGISTRATION

Patient Name_______________________________________________ Age______ DOB_________ Sex_______

Social Security #:_______-_____-______ Person Responsible for Account: ______________________________

Home PH#:______________________ Married_______ Single_______ Divorced_______ Widowed_________

Cell PH#:________________________ Emergency Contact______________________ PH #________________

Patient Address______________________________________________________________________________

Street

City

State

Zip

Email Address___________________@____________ Would you like to receive email communications Y N

Primary Insurance Name________________________________Guarantor:_____________________________

Secondary Insurance Name:_____________________________ Guarantor:_____________________________

Tertiary Insurance Name:_______________________________ Guarantor:_____________________________

Spouses Name ________________________________________ Phone # ________________________________

Patients Employer ______________________________ Work #___________________________ Ext ________

Spouses Employer ______________________________ Work # __________________________ Ext________

Preferred Pharmacy Information: NAME:________________________________________________________

ADDRESS: ____________________________________________________

PHONE #:_____________________________________________________

Does your insurance allow ROUTINE HISTORY & PHYSICALS (please circle)? Y N UNKNOWN

Does your insurance allow ROUTINE LABS (please circle)? Y N UNKNOWN

I hereby authorize Suntree Internal Medicine to furnish information concerning my illness and treatment to the insurance company to help secure payment for any services rendered. I assign all medical benefits to which I am entitled to by Dr. Hardoon / Suntree Internal Medicine for all services rendered. I understand I am ultimately responsible for ALL charges whether approved or not approved by my insurance company. A copy of this authorization will be as valid as the original. This assignment will remain in effect until revoke by me in writing.

If this account is assigned to a Collection Agency, an additional fee of 40% will be added to the amount on my account and I agree to pay this amount. In addition, if this account is assigned to an Attorney for collection/suit, I agree to pay the prevailing party entitled any and all fees and cost of said collection.

Patient / Guardian Signature _______________________________________________________Date:___________________

How did you hear about our office? (Please Check All That Apply)

Referred by Physician

Friend

Family

Insurance Company

Internet

Phonebook

The Talking Phone Book

Face Book

Jan Macinnes (Director of Marketing)

Senior Life

Viera Voice

The Florida Today

Angies List

Military Base Magazine

The Sun Newspaper

Beaches Newspaper

Movie Theatre

TV Ad

Other/Not Listed

903 Jordan Blass Drive, STE# 102 Office: 321-259-9500

Melbourne, FL 32940 Fax: 321-253-1777