Last Name:_________________________ First:_ ________________________M.I.:____

Street Address: ______________________________Home Phone:(______)__________

City:_____________________ State:____________ Zip:______________ Work Phone: (______)__________

Date of Birth:_____/_____/______ Sex:( M / F )_______Social Security Number:________-_____-__________

Are you a student? If YES, _____Full Time _____ Part-time

Marital status: _____Single _____Married _____Other?

Name of Company:______________________ Work Phone: (_________)___________

Address1:____________________________________________

City:__________________________State:__________________Zip:_________

EMERGENCY CONTACT (Friend or Relative not living with you)

Contact Name: __________________________ Phone / Cell: (_________)_____________________

Your relationship to emergency contact (mother, brother, uncle, etc…)?_____________

Primary: ______________________ID or Policy ________________________________

Address:_________________________City_________________State____Zip________

Name of Insured:____________________________________

Group name:______________________ Group #:_________________

Secondary:_____________________________ ID or Policy:_______________________

Address:__________________________City__________State________Zip__________

Name of Insured:____________________________________

Group Name:______________________ Group #:_________________

CONSENT FOR TREATMENT: I, as a patient, consent to medical care including examination, diagnostic, or surgical treatment by the treating physician as may be deemed necessary. I am aware that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of any treatment.

Signature: ____________________________________Date _____/_____/_____

AUTHORIZED RELEASE OF INFORMATION: I hereby authorize Sunlite Health Care to release those medical records pertaining to my treatment to any entity that is responsible for payment of physician charges. I understand that this authorizes my insurance company to pay any benefits directly to Sunlite Health Care. In addition, I further understand that I am ultimately responsible for charges incurred for services rendered.

A photocopy of this authorization shall be considered as effective and valid as the original.

This authorization is in effect until I choose to revoke it in writing.