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