Have this information ready when you call to schedule your first appointment. Information you provide us will only be used for providing care to you or your family member.

• First, middle and last names - as they appear on your birth certificate.
• Date of birth - used to identify and verify you, as well as differentiate you from other patients who may have the same name.
• Social Security Number - used to organize your information. You have the option not to provide this number. If so, another number may be used in its place.
• Address.
• Telephone number(s).
• Marital status.
• Maiden or previous names.
• Employer - name, address and telephone number.
• Emergency contact - whom to call if an emergency occurs while you are in our care, and how to reach them.
• Insurance information - We will need detailed information regarding your insurance plan. Please be sure to bring any insurance documentation (such as plan ID cards) to all of your appointments. Because we often receive insurance plan changes, we may ask you about your insurance at any visit. If your insurance has a co-pay requirement we will request payment at the time of the visit.