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New Patient Registration

Patient Information


Patient Information

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Parent / Legal Guardian Information (if applicable)


Parent / Legal Guardian Information (if applicable)

(**If there are any custodial issues pertaining to this child, you must provide a copy of the custodial agreement**)
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Parent / Legal Guardian Information (if applicable)


Parent / Legal Guardian Information (if applicable)

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Guarantor Information ( Financially Responsible Party )


Guarantor Information ( Financially Responsible Party )

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Insurance Information (We must have a copy of Insurance card(s) in order to file )


Insurance Information (We must have a copy of Insurance card(s) in order to file )

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Emergency Contact


Emergency Contact

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Assignment of Insurance Benefits & HIPPA


Assignment of Insurance Benefits & HIPPA

(**We must have your signature below in order to process insurance claims**)
I hereby authorize the attending Physician to furnish from his records any information requested to any insurance company affording coverage to me or liable third parties in connection with the above assignment. In the event that the undersigned is entitled to Physician benefits, said benefits are hereby assigned to the Physician and paid directly to Palmetto Allergy & Asthma. If insurance benefits are not paid within 45 days of service, charges will be responsibility of the patient. I have received or have been offered a copy of Palmetto Allergy & Asthma's "Notice of Privacy Practices."

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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