Request an Appointment - Hope HealthCare

Departments *

Doctors *

PATIENT INFORMATION

Patient Name *

First

Middle

Last

Marital Status *

Gender *

Male
Female

Who referred you?

Mailing Address *

P.O. Box

Country *

Bermuda
US
Other

Parish *

Zip Code *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone numbers (Primary Number) *

Home
Work
Cell

Home

Work

Cell

Email Address

Please enter your email, so we can follow up with you.

Date Of Birth *

Employer *

Employer Address

POLICY HOLDER

(If Diffrent Than Above)

Relation to patient *

Self
Parent
Spouse
Other

(Please Tick One)

Specify

Name *

First

Middle

Last

Mailing Address *

P.O. Box

Country of policy holder *

Bermuda
US
Other

Parish

Zip Code

Address

Address Line 1

Address Line 2

City

State

Zip Code

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone Numbers

Home
Work
Cell
Fax

Primary Number (Please Tick One)

Home

Work

Cell

Email Address

Date Of Birth

Employer

INSURANCE INFORMATION:

(PLEASE TICK INSURANCE COMPANY)

Insurances *

Group/Policy # *

Certificate # *

Insurance Effective Date *

Member ID # *

Group # *

Guarantor's Name

(If you are a minor, this must be signed by your parent guardian.)

Dated *

I, the undersigned, hereby authorize payment of insurance benefits to the attending Physician for the serice/s rendered to the patient named on this form, together with the release of any medical information necessary to process a medical claim.

Terms & Policies *

I understand

I, understand that I am solely responsible for full payment of all cost/s incurred in the event that my insurance company does not pay, as well as all legal cost from an agency collection if charges are not paid and any expense that may be charged for collection of an outstanding account/s.

Emergency Contact

Name *

First

Last

Telephone Number *

Relationship to the patient *