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LeBauer HealthCare at Brassfield
LeBauer Behavioral Medicine at Walter Reed Drive
High Point
LeBauer Primary Care at MedCenter High Point
Kernersville
LeBauer Behavioral Medicine at Kernersville
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LeBauer HealthCare at Oak Ridge
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LeBauer Summerfield Village
Whitsett
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LeBauer HealthCare at Stoney Creek
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About
Our Story
Our Mission
Join Our Team
Services
Behavioral Medicine
Endocrinology
Gastroenterology / Endoscopy
Primary Care
Neurology
Pulmonary / Critical Care
Sports Medicine
Locations
Find a LeBauer Near You
By City
Burlington
Primary Care
Pulmonary / Critical Care
Greensboro
Behavioral Medicine
Endocrinology
Gastroenterology / Endoscopy
Neurology
Primary Care
Pulmonary / Critical Care
Sports Medicine
High Point
Behavioral Medicine
Primary Care
Kernersville
Behavioral Medicine
Oak Ridge
Behavioral Medicine
Primary Care
Summerfield
Behavioral Medicine
Primary Care
Whitsett
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Behavioral Medicine
Greensboro
High Point
Kernersville
Oak Ridge
Summerfield
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Greensboro
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Greensboro
High Point
Neurology
Greensboro
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Burlington
Greensboro
High Point
Oak Ridge
Summerfield
Whitsett
Pulmonary / Critical Care
Burlington
Greensboro
Sports Medicine
Greensboro
Extended Hours Locations
Providers
By Location
Burlington
LeBauer HealthCare at Burlington Station
LeBauer Pulmonary Care at Burlington
Greensboro
LeBauer HealthCare at Grandover Village
LeBauer Horse Pen Creek
LeBauer Primary Care at Green Valley
LeBauer Behavioral Medicine at Green Valley
LeBauer Pulmonary Care at Elam
LeBauer Gastroenterology / Endoscopy
LeBauer Sports Medicine
LeBauer Endocrinology
LeBauer HealthCare Neurology
LeBauer HealthCare at Brassfield
LeBauer Behavioral Medicine at Walter Reed Drive
High Point
LeBauer Primary Care at MedCenter High Point
Kernersville
LeBauer Behavioral Medicine at Kernersville
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LeBauer HealthCare at Oak Ridge
Summerfield
LeBauer Summerfield Village
Whitsett
LeBauer Behavioral Medicine at Stoney Creek
LeBauer HealthCare at Stoney Creek
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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.
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
(###)### - ####
Work Phone
*
(###)### - ####
Mobile Phone
(###)### - ####
Email
Date of Birth
*
Month
Day
Year
mm/dd/yyyy
Age
*
Please enter a number from
0
to
200
.
Sex
*
Male
Female
Marital Status
*
Race/Ethnicity
*
EMPLOYMENT INFORMATION
Employment Status
*
Unemployed
Full-time
Part-time
Retired
Self-employed
Student
Other
Employer Name
*
Occupation
*
INSURANCE INFORMATION
Optional if you are over 18 and the main policyholder on the plan.
Name of Insurance Carrier
Policy Number
Group Number
Name of Policyholder
Policyholder's Date of Birth
Month
Day
Year
mm/dd/yyyy
Relationship to Policyholder
Policyholder's Employer
Employer Phone
(###)### - ####
Employer Address
Street Address
City
State / Province / Region
ZIP / Postal Code
FOR MINORS
Responsible Party
Relationship
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
(###)### - ####
EMERGENCY CONTACT / NEXT OF KIN
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Relationship to Patient
*
AUTHORIZATION AND VERIFICATION
Initial Here to Authorize Disclosure
*
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.
Date
Month
Day
Year
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