New Patient Form

Height

Feet

Inches

Please enter a value between 0 and 12.

Emergency Contact

Name

Relationship

Phone

Referred By
Employer Information
Employer
Phone
Fax
Address
Street Address Address Line 2 City State ZIP Code
Health Insurance Information
Patient's Relationship to Primary Insured
Name of Insured
Insured DOB
Insurance Company
Insurance ID
Group #
Plan Name
Business Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Email
Please present your insurance card so we can photocopy it.
Secondary Health Insurance
Do you have secondary insurance?
- Yes
- No
Patient's Relationship to Primary Insured
Name of Insured
Insured DOB
Insurance Company
Insurance ID
Group #
Plan Name
Business Address
Street Address Address Line 2 City State ZIP Code
Phone
Fax
Email
Please present your insurance card so we can photocopy it.
Medical Contacts
Serenity Sleep Solutions® coordinates treatment with your other medical providers to ensure maximum benefit to you. Where applicable, please list your other medical providers.
Primary Care Doctor
Phone
ENT
Phone
Sleep Doctor
Phone
Dentist
Phone
Other MD
Phone
Other MD
Phone
I certify this information is true, accurate, and complete to the best of my knowledge.

Patient Information