Proliance Surgeons
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New Patient Information

If you are new to our office, please complete the following form to the best of your ability before your first visit so that we may better assist you. If you opt-in to email communications, a copy of your submission will be emailed to you when you are finished. If your information should change before your visit, please forward your confirmation email to patientforms@proliancesurgeons.com with the changes. Thank you.

1. Contact & Insurance Info2. History Info3. Form Complete
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Patient Information




Financial Responsibility




Emergency contact information:


Insurance Information

Primary Insurance


Secondary Insurance


Insurance Questions

Our office will file insurance for all reimbursable services, to both your primary and secondary insurance carriers. Please remember that you are responsible for all deductible, copay, and non-covered service amounts.


Notice of Privacy Practice

We keep a record of the health care services we provide you. You may ask to see and copy the record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting the administrator of the location at which you have been treated. Please call the main office phone number and ask for the administrator. Our NOTICE OF PRIVACY PRACTICES describes in more detail how your health information may be used and disclosed, and how you can access your information.

Whom may we share your information with including financial account information?