igard.com.sg - New Patient Form

New Patient Registration

In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.
Contact Information
Name*

First NameLast Name
Daytime Phone*
Please enter a valid phone number.
Mobile Phone*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Information (if patient is under 18 years of age)
Name

First NameLast Name
Daytime Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Gender*
Date of Birth*

MonthDayYear
Date
Social Security No.*
Insurance Information

Financial Assignment Information
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Acknowledgment of Notice of Privacy Practices (NPP)
Yes, I have read or had explained to me by this office the NPP & I wish to continue my care under said terms.No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.The NPP could not be read due to the emergent nature of the care needed.
Signature agreeing to all above terms

Clear
Date

MonthDayYear
Date

New Patient Registration