On Line Patient Registration | EAST TEXAS PROSTHETIC-ORTHOTIC CARE

I request that payment of authorized medical benefits be made, when this option is available by insurance carrier, on my behalf to East Texas Prosthetic-Orthotic Care for any services rendered. I authorize the release by any holder of medical records or information related to my prosthetic and/or orthotic needs to East Texas Prosthetic-Orthotic Care and its agents in order to determine appropriate services and verify funding for proposed services.Yes, I Agree To The Terms Above

GENERAL INFORMATION

EMPLOYER INFORMATION

EMERGENCY CONTACT

MEDICAL INFORMATION

Do You Suffer From Any Of The Following Conditions? Select Yes Or No

INSURANCE INFORMATION

Primary Insurance Company

Subscriber Information (Do Not Complete If Same As Patient Information)

Secondary Insurance Company

Subscriber Information (Do Not Complete If Same As Patient Information)

AUTO OR WORKERS COMPENSATION INFORMATION

AGREE TO TERMS

Verification