Help Line : 242-325-1566

Jun 22, 2017

0

The SurgiCentre/The Surgical Suite- Dr. Ross Downes

REGISTRATION FORM

PATIENT INFORMATION
Patient’s last name: First :
Middle: Marital status:

Address (include P.O. Box) Email:

Chose clinic because/referred to clinic by (Please choose one option):

Please state name:
INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)

Please indicate primary insurance: Colina

Atlantic Medical

BahamaHealth

Generali

Other

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize The SurgiCentre/The Surgical Suite- Dr. Ross Downes or insurance company to release any information required to process my claims.
Patient/Guardian signature Date m/d/y