NEW PATIENT REGISTRATION
Patient First Name Patient Last Name Date of Birth (MM/DD/YYYY) Last 4 numbers of your Social Security number (if applicable)
XXX - XX -
       
Address (Please include Apt/Suite Number) City State
       
Zipcode Home Phone Number Cellphone / Pager E-mail
       
Source of Referral      
       
I understand that Dr. Wollschlaeger does not accept insurance assignments and is not a participating provider in insurance plans (including Medicare and Medicaid) and that I'm financially responsible for all charges.
 
I, the patient or guarantor, certify that the information on this form is true to the best of my knowledge.
 
I accept responsability for the medical charges incurred by my person and agree to pay all bills at the time of the service.
 
In the event of default, I agree to pay all costs of collection, and reasonable attorney's fees.
 
I further agree that a photocopy of this agreement shall be valid as the original.
 
I hereby authorize Dr. Wollschlaeger to furnish to insurance companies or their representativesinformation regarding my illness and treatment. All medical information is strictly confidential and can only be released to a third party with my written concern.
 
 



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Aventura Family Health Center - 16899 NE 15th Avenue - North Miami Beach, FL 33162 / Tel: 305-940-8717 / Fax: 305-402-2989