Appointment Date____________________________________Time_______________________

Welcome. Please complete this confidential form to assist us in helping you and caring for your problem.

Patient Name____________________________________________ Birthdate_______________
Address_______________________________________________________________ Sex: M F
______________________________________________________________________________

Problem____________________________________________ Home ph___________________
___________________________________________________ Work ph ___________________
Referring Physician____________________________________ Clinic____________________
Primary Physician_____________________________________ Clinic____________________

Name of Party Responsible for Charges______________________________________________
Address____________________________________________SS#_______________________
__________________________________________________ Home Ph ___________________
Employer___________________________________________ Work Ph ___________________

The patient is my: Self, Spouse, Child, Other___________________________________________
Whom can we notify in case of emergency?____________________________________________
Relationship________________________________________ Phone______________________

Primary Insurance	Secondary Insurance
Ins. Co.____________________	Ins. Co.____________________
Policy Holder________________	Policy Holder________________
Group/Plan #________________	Group/Plan #________________
ID/Contract #________________	ID/Contract #________________
Effective date________________	Effective date________________

I authorize the evaluation and/or treatment of my: Self, Child, Spouse, Dependent
at Minnesota Voice & Speech Clinic___________________(Initial)
I authorize the release of any medical information necessary to process these medical claims. _____________(Initial)
I authorize payment of medical benefits to be made directly to Minnesota Voice & Speech Clinic. ______________(Initial)
I understand that I have the right to keep all my information confidential. _____(Initial)

I understand that I am responsible for all charges regardless of Insurance
coverage.

Signed________________________________ Date____________________