Patient Registration

Patient Registration

"*" indicates required fields

Patient Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Name*
Address*
Choose clinic because/Referred to clinic by*

Please indicate one box.

Pharmacy Information

(Please bring your insurance card to the receptionist.)

In Case of an Emergency

Sign & Date

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Allure Health or insurance company to release any information required to process my claims.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.