Pre-registration Form

Please use the secure form below to pre-register with our office.
This will help to cut down on your wait time on the day of your appointment.


Required fields are marked with *
Please fill out the form as accurately as possible.

 

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PATIENT INFORMATION:

  
*Last Name:
*First Name:
*Middle Initial:
*Social Security #:
*Street Address:
*Apt #:
*City:
*State:
*Zip:
*Home Phone#:
*Birth Date:
*Age: 
*Sex:
Referred by:
Their Address:
City:
State:
Zip: 
List Other Children Seen At This Office:
*Custodial Parent:
*Last Name:
*First Name:
*Middle Initial:
*Birth Date:
*Social Security #:
*Home Phone#:
*Street Address:
*City:
*State:
*Zip:
Employer:
Employer Address:
Business Phone#
Length of Current Employment:
*Marital Status:
*Spouse Name:
*Last Name:
*First Name:
*Middle Initial:
Employer:
Employer Address:
Business Phone#
Length of Current Employment:

Insurance Information:

  

*Primary Insurance Company:
*Name of Insured:
*Social Security # :
*Birth date :
*Relation to Child:
*Policy #:
*Group #: 
*Address :
*City:
*State:
*Phone #:

Secondary Insurance Company:
Name of Insured:
Social Security # :
Birth date :
Relation to Child:
Policy #:
Group #: 
Name of Insurance Company:
Address :
City:
State:
Phone #:

Assignment of Insurance Benefits & Information Release

By clicking submit, I authorize the release of any medical information necessary to process insurance claims. I hereby assign payment directly to Cornerstone Medical Associates of the basic benefits as well as Major Medical Benefits herein specified, and otherwise payable to me, but not to exceed the regular charges for this period of treatment. I understand I am financially responsible for any charges not covered by this assignment. Payment is due at time of service unless prior arrangements are made with this office.
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