2024 Registration and Consent to Treatment

Welch Pasteur Allergy Medical Group, Inc

Anita Carmen Choy, MD. |. Hailen Mak, MD
211 Quarry Road, Suite 106 MC 5996,
Palo Alto, CA 94304
Ph: 650.322.3847 | Fax: 650.322.3249

Patient Registration & Consent to Treatment Form

Last Name

First Name

Middle Initial

Date of Birth

Sex

Male

Female

Marital Status

Single

Married

Widow/Widower

Divorced

SSN #

Address

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Work Phone

Email

Driver's License Number

Race

Asian

Hispanic

Caucasian

African American/Black

American Indian/Native American

Native Hawaiian/Pacific Islander

Other

Occupation

Employer

Referred By

If Doctor, provide phone:

If Under 18: Parent or Guardian Name

Emergency Contact Name (other than spouse)

Relationship

Emergency Contact Address

Emergency Contact Phone

Primary Insured Information

Primary Insured Name

Policy Holder

Policyholder DOB

Policyholder SSN

ID#

Group#

Name of Employer

Position

Employer Phone

Employer Address

Secondary Insured Information

Secondary Insured Name

Policy Holder

Policyholder DOB

Policyholder SSN

ID#

Group#

Name of Employer

Position

Employer Phone

Employer Address

Assignment of Insurance Benefits

By my signature below, I hereby authorize direct payment of surgical/medical benefits to Dr.:

for services rendered by him/her in person under his/her supervisor.

I understand that I am financially responsible for any balance not covered by my insurance. I certify that the information given by me in applying for payments is correct. I request that payment of a authorized benefits be made on my behalf

Consent to Medical Treatment and Allergy Testing

I authorize the doctors at the Welch Pasteur Allergy Medical Group, Inc to undertake appropriate investigation and to give me treatment deemed medically reasonable.

Patient Name

Date

Patient/Guardian Name

Signature

Clear