EXPRESS PAY

SOUTHERN IDAHO PAIN INSTITUTE

CALL FOR APPOINTMENT

Demographics Form Specialists & Anesthesiologist in Twin Falls

Demographic

Hidden

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

About You

MM slash DD slash YYYY
Patient's Name(Required)
Gender(Required)
Marital Status(Required)
Mailing Address(Required)
Physical Address
Do you currently reside in a Nursing Care Facility?(Required)
Employment Status(Required)
How did you hear about our office?(Required)
Authorization to leave information on voicemail or answering machine(Required)

Medical Information

Is your visit Accident Related?(Required)
Do you have a medical power of attorney:(Required)
Do you have an Advanced Directive:(Required)

Insurance Information

Is your visit Accident Related?(Required)
If yes, Do you have an Attorney?(Required)
Authorization to download Medication history(Required)
Today I will be paying by(Required)
I hereby authorize the physicians of this office and their designates to provide medical treatment release of information pertaining to my treatment for insurances purposes. I understand that I am financially responsible for all professional services rendered. I authorize the insurance company to pay benefits directly to the physician. I understand that I am responsible to supply all necessary information, such as insurance information, authorizations, and referrals, so that my insurance can be properly filed. I further agree to pay all collections costs, reasonable attorney fees, and other collections costs that may be incurred to enforce collection of any amounts outstanding.
Consent
MM slash DD slash YYYY

REAL PATIENTS Patient Testimonials & Reviews

When it comes to our patient, they are our top priority. As seen in our reviews, we take care of them like our own family. If you ever have a question, please feel free to contact us. We are always just a call away.

LEAVE A GOOGLE REVIEW
SEE ALL REVIEWS

All reviews are organic from real patients.

SOUTHERN IDAHO PAIN INSTITUTE

Quick Links

Doctors

Opening Hours

  • Monday..........8 AM–5 PM
  • Tuesday..........8 AM–5 PM
  • Wednesday...8 AM–5 PM
  • Thursday........8 AM–5 PM
  • Friday.............7 AM–5 PM
  • Saturday.................Closed
  • Sunday....................Closed

Copyright © Southern Idaho Pain Institute

Site Powered by Next Level Solutions