NEW PATIENTS!: PLEASE FILL OUT REQUIRED FORM

NAME:
D.O.B.:
SSN:
ADDRESS 1:
ADDRESS 2:
ZIP CODE:
PRIMARY CARE PHYSICIAN:
MEDICATIONS:

INSURANCE:
PRIMARY HOLDER:
PATIENT RELATION TO PRIMARY HOLDER:
PLAN:
CO-PAY:
REQUIRE A REFERRAL: YES OR NO

WE ARE NOT RESPONSIBLE FOR YOUR HEALTH, WELLNESS, OR ANY MEDICAL CARE RECEIVED AT THIS FACILITY OR ELSEWHERE. IF YOU CONTINUE TO BE SICK IT IS UP TO YOU TO SEEK FURTHER TREATMENT HERE OR ELSEWHERE. OUR DOCTORS ARE NOT RESPONSIBLE FOR THE EFFECTS OF TREATMENTS PRESCRIBED OR COSTS INCURRED AS RELATED TO EFFECTIVENESS OF TREATMENT RECEIVED. YOU ARE ON YOUR OWN. YOU WILL BE SICK FOREVER AND EVENTUALLY YOU WILL DIE. THAT IS NOT OUR PROBLEM. WE ARE A BUSINESS AND WE ARE HERE TO MAKE MONEY OFF OF AS MANY SICK PEOPLE AS POSSIBLE. THANK YOU FOR CHOOSING SACRED HEART HEALTH GROUP. WE LOOK FORWARD TO SERVING YOU.

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