Registration & Consent Form
Referring Doctor:
Referring Doctor Location
First Name:
Last Name
Date of Birth:
Gender:
Female:
Male:
N/B:
Any Chance of Pregnancy:
Yes:
No:
Mailing Address:
Email:
City:
State:
ZIP Code:
Phone Number:
REVEAL DOES NOT PROCESS INSURANCE
Check this box if you would like an ADA dental claim form and completion instructions
CONSENT & RELEASE
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I consent to allow Reveal Diagnostics to use and disclose my
HEALTH INFORMATION
in order to carry out treatment and healthcare operations.
By signing this form, I am consenting to Reveal Diagnostics use and disclosure of my information as detailed above. However, I may give notice to restrict the use of such information and revoke my consent in writing. I understand that I have the right to review the
NOTICE OF PRIVACY PRACTICES
for a more complete description of such uses and disclosures prior to signing the consent.
Patient Signature
Date:
FINANCIAL RESPONSIBILTY
I accept full financial responsibility for all charges for my examination today and will pay at time of service. I understand that I will have to submit my own claim form to insurance for reimbursement.
Patient Signature
Date:
Locations ■ San Francisco ■ Mountain View ■ Oakland ■ San Jose
■info@revealdiagnostics.com ■revealdiagnostics.com ■phone 415-837-5990 ■Fax 888-808-6160