Sex: [ ] Male [ ] Female Marital Status

Patient Registration Information

PATIENT’S PERSONAL INFORMATION: Sex: [ ] Male [ ] Female Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed Patient Last Name:________________________ Patient First Name:__________________ Middle:__________ Date of Birth: ________/ ________ /___________ Social Security #: __________/__________/________________ Home Phone: (______) _______/________________Cell Phone: (____)_______________/___________________ Address: ___________________________________________________________________ Apt #: _____ City: ___________________________ State: _________________ Zip:___________ Email Address:__________________________________________________________________________

PATIENT/RESPONSIBLE PARTY INFORMATION: Relationship to Patient [ ] Self [ ] Spouse [ ] Other ______ Last Name: ___________________________ First Name: _________________________ Middle:_____________ Date of Birth: _________/__________/__________ Social Security #: ___________/____________/___________ Home Phone: (_______)_________/____________ Cell Phone: (_______)___________/____________________ Address:____________________________________________________________________ Apt #: ______ City:_____________________________________ State:_______ Zip:____________ Email Address: _____________________________________________________________________________

EMERGENCY CONTACT: Name: ________________________________________ Relationship: _________________________________ Home/Cell Phone: (________) ______________/__________________ Email Address:_____________________________________________

Assignments of Benefits * Financial Agreement: Initial [ ]
I hereby give authorization for payment of insurance benefits to be made directly to East Lake Medical Clinic, Pllc., Dr. Dustin Ly and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all cost of collections, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release any and all information necessary to secure the payment of benefits.
With this consent, East Lake Medical Clinic, Pllc may also call my home or cell and leave a message on voicemail or in person in reference to any item that assist the clinic in

carrying out healthcare operation, such as appointment reminders, insurance information and any calls pertaining to my clinical care, including laboratory results among others

I hereby give my consent for East Lake Medical Clinic, Pllc to use and disclose protected health information (PHI) about me to carry out healthcare operations (i.e treatment, diagnostic procedures, and payment).
[ ] Release my Protected Health Information to:
Name: _________________________________________Relationship:__________________

Name: ________________________________________ Relationship:___________________

I understand that I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, East Lake Medical Clinic, Pllc may decline to provide treatment to me.
I further agree that a photocopy of this agreement shall be as valid as the original.
Signature: __________________________ Relationship:________________ Date:__________
Patient Missed Appointment Policy: Please kindly give us a 24hr notice if you cannot attend a scheduled appointment or wish to reschedule. A $25 fee will be charged for any missed appointment without prior notice. We thank you for your understanding. Initial [ ]

4737 Old Canoe Creek Rd P: 407-705-3222 F: 855-332-1560

St. Cloud, FL 34769 www.EastLakeMed.Com page