Marvel Clinic - Ear, Nose and Throat - Cosmetic Surgery

Patient Registration and Agreement
Marvel Clinic

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Patient's email address (Required)

Patient's Last Name

First Name

Middle Name

Street Address

Apt. No.

City

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Patient's Occupation

Employer's Name

Social Security Number

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First Name
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Last Name

Street Address

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Business Phone

Employer

Employer's Address

Spouse

Name of Spouse's Employer

Insurance Information

Patient's Insurance Number

Insurance Company Name

Insurance Company's Address

Policy Holder's Name

Insurance Company Contact Number

I, the undersigned, hereby authorize The Physicians and Healthcare Specialists at The Marvel Clinic to take before and after photographs of areas in which cosmetic surgery will be performed. I also understand these photographs may be shown to other potential patients whom are considering cosmetic surgery. Confidentiality and professionalism will be maintained by the physician and his staff.

I, the undersigned, hereby agree to pay all amounts and charges hereafter incurred by myself and members of my family for services rendered. Failure to make a payment when requested or agreed is basis for legal action and the undersigned agrees to pay all costs of collection including a reasonable attorney fee and hereby waive their rights of exemption under the laws of the State of Tennessee and any other state. I understand the fees of The Physicians and Healthcare Specialists at The Marvel Clinic may exceed the amount paid by my insurance. I understand that the terms are cash at the time of services and that I will be given a complete insurance voucher and receipt signed by the doctor on the same day of each office service. I agree to pay 1 ½ percent interest charge/month on any outstanding balance.

INSURANCE AUTHORIZATION AND ASSIGNMENT

I HEREBY AUTHORIZE THE PHYSICIANS HEALTHCARE SPECIALIST AT THE MARVEL CLINIC TO FURNISH INFORMATION TO INSURANCE CARRIERS, CONCERNING MY ILLNESS AND TREATMENTS AND I HEREBY ASSIGN TO THE PHYSICIAN ALL PAYMENTS FOR MEDICAL SERVICES. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE.