Dr. Tarsem L Singhal

5370 Schaefer Ave, Suite C Chino, CA, 91710 USA

909.548.6200

Patient Information

Date
Phone
Patient Name:
SS/HIC/Patient ID #
Email
Cell Phone
City
State
Zip
Sex
Age
Birth Date
Patient Status:
Patient Employer/School
Occupation
Employer/School Address
Employer/School Phone
Who may we thank for refering you?
In case of emergency who sholud be notified?
Phone

Primary Insurance

Person responsible for this account
Relation to Patient
Birth Date
Soc. Sec.#
Address
Phone
City
State
Zip
Person Responsible Employed by
Occupation
Business Address
Business Phone
Insurance Company
Contract #
Group #
Subscriber #
Names of other dependents covered under this pain

Additional Insurance

Is patient covered by additional insurance?
Subscriber Name
Relation to Patient
Birth Date
Address
Phone
City
State
Zip
Subscriber Employed by
Phone
Insurance Company
Contract #
Group #
Subscriber #
Names of other dependents covered under this pain

Assignment and Release

I certify that I, and/or my dependent(s),have insurance coverage with and assign directly to Dr. all insurance benefits,if any,otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named physician may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for seiVices and determing insurance benefits or the benefits payable for related services.This consent will end when my current treatment plan is completed or one year from the date signed below.

Patient's Signature:

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Date:

Parent/ Guardian Signature:

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Date:
Relationship to Patient: