New Patient Registration Form

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Patient Name:*

Gender:*

Male

Female

Primary Care Doctor (PCP):

Pharmacy name:

Pharmacy address:

Registration number:

Home Address:*

Street Address City State ZIP Code

Home Telephone:

Patient’s SS#:*

Patient’s Birthday: *

Cell:*

Email Address:*

Referred by:*

Referring Physician: *

Responsible party for patient:*

Relationship:*

Emergency Contact:*

Telephone:

Primary Insurance:*

Address:

Subscriber/Policyholder:

Subscriber SS#:*

Subscriber Date of Birth:*

Relationship to Patient:*

Home address:

Employer:*

Telephone:

Cell:

Patient agrees & acknowledges that he/ she is responsible for all attorney fees and costs incurred by Penn Medicine, Dr. Kirkland N. Lozada should any type of legal action be required to collect any unpaid balances by patient and/ or the retention of an attorney by Penn Medicine, Dr. Kirkland N. Lozada be required.

I authorize Kirkland N. Lozada MD, to furnish information to my insurance carrier(s) concerning my illness(es) and treatment. I hereby assign all insurance payments to Kirkland N. Lozada, MD C/O Penn Medicine, Dr. Kirkland N. Lozada and agree to accept full responsibility for all charges for medical services provided to myself and/or any dependents that may not be covered by insurance. WITHOUT EXCEPTION, any charges for any medical services that are not covered by insurance are the full responsibility of the patient, or the responsible party who has signed for this patient.

SIGNATURE:*

Date*

(If patient is a minor, relationship of person signed)

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