Patient Registration - Woodinville Women's Clinic

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					                                          Woodinville Women’s Clinic

                                                Patient registration
 Zora Pesio and staff welcome you. We will strive to provide you with the best possible healthcare. To help us meet
your healthcare needs, please fill out this form completely in ink. If you have any questions, please ask.

If you are here for a YEARLY EXAM it must be billed as a ROUTINE EXAM. The insurance companies require
we bill the intent of the office visit. Please understand medical insurance is your coverage, not ours, we bill as a
service to our patients. We cannot guarantee payment by your insurance company. It is your responsibility to first
check with your insurance company and your particular plan to see if your visit is covered.

We reserve the right to charge for appointments cancelled or broken without a 24-hour notice.

This section is about you:

Name:_____________________________________ M               F     Age:______    Birthdate:____/____/_______

Home Address:___________________________________ City:______________                  State:_____ Zip:_______

Social security #:____-____-______     Home Ph. (____)______________ Cell/Pager(____)_________________

Employer:_______________________         Work Address:____________________________            Suite #:_________

City:___________________       State:_______    Zip:_______      Work Phone: (____)______________ Ext.:_____

Part Time:____    Full Time:____    Marital Status: Single___ Married___ Widowed___ Divorced___

If 18 Years or older, has an advanced directive been executed? Y / N If yes, do we have a copy?____________

This section is about your emergency contacts:

Name:________________________ Relation:________ Home Ph.:(___)__________Work Ph:(___)__________

This section is about insurance coverage for the patient:

Employer:____________________________________ SSN/ Subscriber ID#:____________________________

Subscriber DOB___/___/_____        Subscriber Ph.:(____)________________ Work Ph.:(____)________________

Subscriber Address:______________________________ City:______________ State____ Zip:_____________

Relationship to patient:_________________________________________________________________________

Authorization for treatment and financial agreement:

The above information is true to the best of my knowledge. I understand I am responsible for charges associated
with medical services, and agree to pay all bills within 30 days from the receipt of statement. I authorize
Woodinville Women’s Clinic to release any information to process insurance claims. I also authorize my insurance
to be paid directly to the clinic.

I hereby agree to give my credit card number to you when you call, to take care of ANY balances beyond 30 days of
my first billing cycle. This is including no-shows, and cancellation without sufficient notice.

Signed:_____________________________________________________                Date:_________________________

Signed:_____________________________________________________                Date:_________________________
How did you find out about our office?___________________________________________________________

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