Children's Orthopedic Specialists, PC ::

Children's Orthopedic Specialists Online Registration

PERSONAL INFORMATION * Indicates a required field

*Patient's Last Name:**	*First: MI:**
*Patient's DOB:**	*Male: Female:*
*Patient's Street Address:**
*City:**	*State: Zip:*
*Home Ph. #:**	Email Add:
Primary Care Physician:	Physician's Ph. #:

RESPONSIBLE PARTY INFORMATION * Indicates a required field

*Resp. Party Last Name:**	*First: MI:**
*Resp. Party Home Ph. #:**	Resp. Party Work Ph. #:
Employer:
Employer Street Address:
City:	State: Zip:

INSURANCE INFORMATION * Indicates a required field

*Primary Ins. Company:**
*Primary Ins. ID #:**	Primary Ins. Group ID #:
Secondary Ins. Company:
Second. Ins. ID #:	Second. Ins. Group ID #:

Fill out the following if the Insured is different from the Patient or above Responsible Party.

Name of Insured:
Insured's Street Address:
City:	State: Zip:
Insured's Home Ph. #:	Insured's Work Ph. #:

I hereby authorize treatment by Hank D. Bratt, MD and/or Kent A. Vincent, MD. I authorize the release of any information regarding said treatment to the above listed insurance company(ies) and to my primary care physician as required for payment of all services received. I hereby assign any & all such payments directly to Children's Orthopedic Specialists, PC. I fully understand that I am responsible for any and all charges not covered by my insurance company or as the result of failure to provide accurate patient and insurance information.