Patient Demographics

Patient Demographics

Address(Required)

Insurance

Primary Insurance

Secondary Insurance

*EMAIL ID AND INSURANCE CARDS TO bridgepointclinic@outlook.com*

Visit Information

(Spouse, Parents, Children, Siblings, Other)
(include dosage and frequency)
(include dosage and frequency)
(Inpatient Admission, Previous Providers, Prior Dx, Testing, Etc...)

Signature Acknowledgement

Your signature acts as a comprehensive signature acknowledgement for the following forms and policies. These forms have been sent to you through the patient portal, are available on the website, and can be printed for you at your request. You further acknowledge that you have read, understand, and accept each policy in its entirety.

HIPAA Form • Controlled Substance Agreement • Payment Policy • Treatment Consent

MM slash DD slash YYYY