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Patient name: __________________________________________________________________
LAST FIRST MIDDLE
Date of Birth: __________ Age: _______________________ (please circle :) Female Male
Address: ________________________________________Responsible Party SS#:____________
Required If patient a minor and/or full-time student
City: ___________________________________ State: _____ Zip: _________________________
Home Phone # ____________________________ Work/ Cell Phone # ________________________
Patient SS# _____________________________ Drivers License #________________________
Employer:_______________________________ Occupation: ____________________________
Employer’s City: __________________________ State: _________ Zip: ________________
Marital Status (please circle): Married Single Divorced Widowed
Name of Spouse: ___________________________________ Spouse’s Work Phone # __________________________
Primary Insurance Company: ___________________ Name of Insured:________________________
Relationship to Insured: _______________________ Insured’s DOB: _________________________
Insured SS # ____________ Group Name/Number: ________________ Policy #_________________
Secondary Ins: ______________________________ Name of Insured: _______________________
SEVEN OAKS WILL ONLY BILL 2ND IF WE ARE CONTRACTED PROVIDER
SS# / Policy # of insured: ________________________ Insured’s DOB: _________________________
Referring Physician: ____________________ Phone #: ____________ Fax #: ___________________
Date of Injury/Start of Symptoms: ________ Area of Body to be treated _______________________
INSURANCE REQUIRES THE DATE, MONTH AND YEAR (WILL NOT PAY WITHOUT THIS INFORMATION)
Type of Accident/Illness: __________________________ No ___ Yes _______________________
(Home? Work? Sports? Auto?) Do you have an Atty? If so, Name & Tel number
I DO HEREBY ASSIGN all insurance benets to be paid directly to Seven Oaks Rehabilitation & Fitness Center for all medical services provided to
me. I also acknowledge that I am personally liable for all charges incurred by me for treatment services provided me by Seven Oaks Rehabilitation
& Fitness Center. I further authorize Seven Oaks Rehabilitation & Fitness Center to release information required regarding the course of my
treaunent, for the purpose of evaluating and administering claims for benets. I understand I am responsible for services not cover by my insurance,
i.e. benets exhausted or do not meet criteria of medical necessity per your pJan’s guidelines. I have been informed of & agree to abide by the
cancellation policy. ANY PERSONAL BALANCE 30 DAYS OR MORE PAST DUE MAY BE SUBJECT TO A 1.5% FINANCE CHARGE.
_____________________________________ ______________
SIGNATURE OF PATIENT / PARENT IF MINOR DATE
____________________________________ ______________
SIGNATURE OF RESPONSIBLE PARTY / PARENT IF PATIENT IS FT STUDENT DATE
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PATIENT INFORMATION SHEET ACCT # PT