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
