NEW Preregistration Form


Patient Information
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  13. (valid email required)
Primary Insurance
Secondary Insurance
Reason for Visit
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  2. Is this visit related to a motor vehicle accident?
  3. Is this vist related to a work injury?
  4. Do you plan to file a lawsuit related to the condition you are here to have evaluated?
  5. If you are a female patient, are you pregnant?
Pharmacy Information
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  1. By clicking "Save my place in line", I hereby authorize Dr. Bjorn Dimberg to furnish all information concerning my illness and treatment to the insurance company to help secure payment for services rendered. I understand that certain insurance claims may be filed as a courtesy. However, if for any reason the claim is denied, I am responsible for payment. Please remember that insurance is considered a method of reimbursing the patient for fees to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. I understand it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid by my insurance or third party payer within a period of time not to exceed 60 days. I understand that requests for completion of temporary sickness forms such as FMLA, Aflac, or travel changes will incur a $75 fee for completion.
 

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