Patient Information

Liza Maniquis-Smigel, MD LLC

Physical Medicine & Rehabilitation

Spine, Sports & Electrodiagnostic Medicine

Prolotherapy

Patient Registration

Referring M.D.* Today's Date

Patient Name: Last, First and Middle* Date Of Birth* Age Sex Male Female Mailing Address* Physical Address Phone Home* Phone Work Cell/Msg Current Employer* Position* Employer Address* In Case Emergency Contact Name* Relationship To Patient* Emergency Contact Address* Emergency Contact Phone Number*

Insurance and Financial Responsibility

Are these visits covered by medical insurance?* Yes No Type Of Insurance*

Responsible Party (If other than patient or if patient is a minor/dependent)

Responsible Party Name* Responsible Party Relationship To Patient* Responsible Party Address* Responsible Party Phone Number* Responsible Party Date Of Birth* Responsible Party Employer* Responsible Party Employer Address* Please Check One* AUTO ACCIDENT INDUSTRIAL (WORK)ACCIDENT Date Of Accident

Insurance Company* Policy or Claim Number* Adjuster Insurance Company Address* Insurance Company Phone*

Please Complete Below If It's Work Injury

Employer Supervisor Address Phone

Security Check