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Patient Registration
(En
Espaņol)
After filling out
this form, please print it and bring it with you when you visit Dr. Wesman's office.
Patient Name:
Birth (ex. 05/06/93):
Home Address:
City: State:
Zip:
Home Phone Number:
( )
Daytime/Cell Phone: ( )
Parent(s)
Occupation:
Responsible
Party
Name:
Date of Birth (ex. 5/6/99):
Social Security #: -
-
Relationship To
Patient:
Patient Gender: male female
Have you been to Dr. Wesman's office before? yes no
Referring
Physician:
Address:
Phone: ( )
Primary Care Physician on Record with Your Insurance Company:
Insurance Information
Insurance Co. Name:
ID#:
Group# :
Name of the Primary
Insured:
My child is covered
by the insurance carrier listed above and I assign directly to Robert
Wesman MD all surgical and/or medical benefits including any major
medical 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 hereby authorize the doctor to release
all information necessary to secure the payment of benefits.
Date:
Signed: _______________________________________________
Dr. Robert Wesman,
M.D.
Pediatric
Ears, Nose & Throat
744 52nd
St. Suite 4200
Oakland,
CA 94609
(510)
428-3456
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