Patient Registration Form

Save time in the waiting room. Submit your patient registration information before your appointment by filling out this form. Your information will be emailed to the office manager at the location you select.
  • Please select the LeBauer Primary Care location at which you would like to schedule your appointment.
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  • mm/dd/yyyy
  • Please enter a value between 0 and 200.
  • EMPLOYMENT INFORMATION

  • INSURANCE INFORMATION

    Optional if you are over 18 and the main policyholder on the plan.
  • mm/dd/yyyy
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  • FOR MINORS

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  • EMERGENCY CONTACT / NEXT OF KIN

  • AUTHORIZATION AND VERIFICATION

  • I authorize LeBauer HealthCare to release medical information that may be necessary to request reimbursement by my insurance company to whom I have submitted claims. I understand I am responsible for all medical fees during my treatment with LeBauer HealthCare. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medical, private insurance, and other health plans to: LeBauer HealthCare.
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