Brand New Med Enrollment Form
Enrollment and Fee Itemization
Patient Name ( First, Middle and Last Names) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Spouse/Partner Full Name ( if applicable)
Your answer
Spouse/Partner Date of Birth
MM
/
DD
/
YYYY
Spouse/Partner Age
Your answer
Children to Whom This Agreement Applies ( Name , DOB and Age)
Your answer
Children to Whom This Agreement Applies ( Full Name , DOB and Age)
Your answer
Children to Whom This Agreement Applies ( Full Name , DOB and Age)
Your answer
Children to Whom This Agreement Applies ( Full Name , DOB and Age)
Your answer
Preferred Payment Method *
Fee Itemization *
Required
Were you referred to our practice?? *
I certify that I have read, understand , and agree to the terms set forth in the BRAND NEW MED Medical Agreement form. *
By completing this form I am giving my consent for treatment to BRAND NEW MED and acknowledging that I have received a copy of the Notice of HIPPA Privacy Practices. *
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