New Patient Form – Apollo MH

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Last Name

First Name

Date of Birth

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Name

Phone

Relationship

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Name (copy)

Phone (copy)

Relationship (copy)

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First Name

Middle Initial

Last Name

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Date of Birth

Address

City

St.

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Zip

Home Phone

Cell Phone

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Relationship to Patient

Occupation

Checkboxes

I hereby authorize Apollo Men's Health to furnish information to my insurance carrier(s) concerning my illnesses and treatments. INITIAL I hereby assign to Apollo Men's Health all payments for medical services rendered to me or my dependents. INITIAL I understand that I am responsible for any amount NOT covered by my insurance company. INITIAL I am also aware that Apollo Men's Health will bill me for any co-pays or deductible owed by the patient, if not collected at the time of service. INITIAL

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