Patient Information – West Houston Allergy & Asthma

New Patient Information

Patients forms

"*" indicates required fields

Age

Date

Patients Name*

Sex

Male

Female

Date of Birth*

Patients Parent Name*

Primary Phone:

Secondary Phone

Home Address

Street Address City State Zip Code

Employer Name

Employers Address

Street Address City State Zip Code

Employer Phone

Name of nearest relative (not living with you)*This person will be notified in case of an emergency

Phone

Name of Insured

Relationship of patient to insured

Date of Birth*

SS#

Insured’s Employer Name

Insured’s Employer Address

Insured’s Employer Home Address (if different from above)

Phone

Name of referring physician

Phone

Name of primary care physician

Phone

All information submitted above is true to the best of my knowledge. I authorize the release of any medical or other information to process claims and I authorize payment Of medical benefits to West Houston Allergy & Asthma, P.A.-Dr. Pardeep S. Rihal. I authorize consultation and treatment for services rendered.

PLEASE NOTE THAT BENEFITS THAT ARE QUOTED ARE NOT A GUARNTEE OF COVERAGE, WE RECOMMEND THAT THE INSURED CONTACT HIS/HER INSURANCE COMPANY TO DETERMINE BENEFITS AND ELIGIBILITY. THE INSURED IS RESPONSIBLE FOR ALL CHARGES (i.e. deductibles, pre-existing conditions, etc.) THE AMOUNT COLLECTED MAY NOT BE THE FINAL CHARGES AS THESE WILL BE DETERMINED AFTER YOUR CLAIMS ARE PROCESSED BY THE INSURANCE COMPANY.

Pharmacy Number

Signature of Patient/Responsible party*

Date

New Patient Information

Patients forms

Useful Links

West Houston Allergy & Asthma, Katy, TX

West Houston Allergy & Asthma, Richmond, TX