Adult Patient Demographics Last Name*First Name*MIAddressCitySTZipCellHome*WorkEmail* GenderMaleFemaleMay we send text appointment reminders?YesNoE-Mail?YesNoDate of Birth:* Date Format: MM slash DD slash YYYY Marital Status Single Married Divorced Widowed Partner EmployerOccupationEmergency Contact NamePhoneHow did you hear about our practice? Patient Agreement I, the undersigned, am aware that I am financially responsible for all services rendered to me by Feldman ENT and Renu Med Spa. I am aware that I am personally responsible for all co-payments, deductibles, and non-covered services as dictated by my insurance coverage. I, the undersigned, hereby authorize Feldman ENT and Renu Med Spa to apply for benefits for covered services rendered by the Practice and request that the payments from my insurance carrier are paid directly to the practice. I certify that the information I have provided with regard to my identity and insurance coverage is correct, and further authorize the release of any necessary information, including medical information for this or any related claim to my insurance carrier(s). I permit a copy of this authorization to be used in place of the original. I, the undersigned, am aware that I will be charged a No Show fee of $150.00 for any appointment I cancel without a twenty-four (24) hour noticeSignature*Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.