Registration form for virtual visit

Patient’s First and Last Name*
First Last
Patient’s Date of Birth*
MM slash DD slash YYYY
Social Security Number or Driver's License Number (for any patient over 18 years of age)
Address*
Street Address City State / Province / Region ZIP / Postal Code
Contact Phone Number*
E-mail Address*
Sex*
- Male
- Female
- Transgender
Symptoms
Medical History
Current Prescriptions
Drug Allergies*
Financial Responsibility (for any patient under 18 years of age) Name
Financial Responsibility DOB
MM slash DD slash YYYY
Financial Responsibility SSN
Primary Insurance Carrier Name*
Member Number*
Group Number*
Secondary Insurance Carrier Name
Secondary Insurance Member Number
Secondary Insurance Group Number
Consent*
I agree to the below terms
PATIENT AND RESPONSIBLE PARTY AUTHORIZATION I authorize SCFM Convenience Clinic, LLL to apply for benefits on the patients behalf for the covered services rendered and request that payments from the above named insurance company(ies) be made directly to SCFM Convenience Clinic, PLL for the treated person named. I certify that the information reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim to the above named agent. I permit a copy of this authorization to be used in place of the original. IN ALL CASES, PROFESSIONAL FEES ARE THE PATIENT, SPOUSE, GUARDIAN AND/ OR PARENTS’ RESPONSIBILITY. Finance Charge (no charges if paid in 30 days of billing date) may be computed by a “Periodic Rate” of 1 1/2% per month, which is an ANNUAL PERCENTAGE RATE of 18% applied to the previous balance without deducting current payments and/or credits appearing on any given bill. Patient or responsible party(ies) further agree to pay any and all collection fees incurred and legal expenses, including but not limited to Collection Agency and attorney fees, all court related costs, service and filing fees, interrogatory and garnishment fees as well as any interest that may be adjudicated for the collection of past due debts.
Copy of Insurance Card with Responsible Party Drivers License
Max. file size: 128 MB.