Request an Appointment

Patient Information

Today's Date
Please choose two appointment dates in order of preference MM/DD/YYYY
Time of Day:	Morning Afternoon Either
Primary Orthopaedic Problem:
Primary Care Physician*
Referring Physician*
Appointment Physician*
First/Middle/Last Name/Suffix*
Social Security Number* 123-45-6789
Date of Birth* 01/01/1980
Sex/Martial Status	Male Female Married Single Widowed
Occupation
Employer
School
Home Address*
City, State Zip*
Home Phone* 706-555-1234
Work Phone 706-555-1234
Cell Phone 706-555-1234
Nearest Friend/Relative
Relationship
Home Phone 706-555-1234
Work Phone 706-555-1234

Guarantor Information

Person Responsible For Bill First/Last Name/Suffix
Address
City, State Zip
Sex / Race	Male Female
Relationship to Patient
Phone
Social Security Number 123-45-6789
Date of Birth 01/01/1980
Company Name
Company Address
City, State Zip
Company Phone
Occupation

Insurance Information (Primary)

Insurance company name
Name of Insured First/Last Name/Suffix
Relationship to Patient
Date of Birth 01/01/1980
Policy/Group Number
Social Security Number 123-45-6789
Insured's Employer
Work Phone 706-555-1234

Insurance Information (Secondary)

Insurance company name
Name of Insured First/Last Name/Suffix
Relationship to Patient
Date of Birth 01/01/1980
Policy/Group Number
Social Security Number 123-45-6789
Insured's Employer
Work Phone 706-555-1234

Authorization For Treatment and Financial Agreement By checking this box I agree to the following:
I authorize treatment of the person named and authorize information given to the insurance companies. I agree to pay all charges and interest shown by statements, promptly upon presentation thereof, unless credit arrangements are agreed upon in writing with the clinic.

It is agreed that payment will not be delayed or withheld because of any insurance coverage of the pendency of claims thereon, and that all proceeds of the insurance for services rendered are assigned to Advanced Gynecology Associates of Augusta but without the practice assuming sole responsibility for the collection thereof.