2660 10^th Ave. South

POB 1, Suite 301

Birmingham, Al 35205

Phone: 205-930-2369

Fax: 205-930-2715

 




Date

Driver’s License  

Date of Birth  

       
Full Name                                                            Social Security Number



                    
Address                                                               City                                          State                           Zip Code



             
Home Phone                    Cell Phone                        E-mail address



       
Where Employed                                   Work Phone



                 
Primary Insurance                           Policy or ID #            Group #                      Policy Holder



                   
Secondary Insurance                      Policy or ID #             Group #                     Policy Holder



         
Marital Status           Spouse Name                                       Spouse Date of Birth



   
Spouse Employer Name                                     Telephone #




Name and Number of person to notify in case of Emergency (other than spouse)




Referred by Whom?




Please list any medications you are currently taking




Please list any known allergies




In carrying out my treatment, it might be necessary to FAX my records to the hospital or to a doctor’s office. By signing below I am authorizing the release of my medical records in this fashion.




It is the patient’s responsibility to notify this office of any insurance changes.




I understand that I am responsible for any and all charges incurred by me and that I agree to pay any collection costs incurred including a reasonable attorney’s fey.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Demographics Sheet

Unique Document ID: abbc0a5d239a6ea6b0094a425fe1e5e69edf75a0

Build. Track. Sign Contracts.

Timestamp	Audit
January 22, 2021 9:54 am CDT	Demographics Sheet Uploaded by Dylan Richardson - dylan@danmarkcom.com IP 12.233.60.59

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://www.stvsleep.com/

Audit Trail Serial# 852755d18cea74d935483b6ca777619c