Align Clinic, LLC

PATIENT INFORMATION FORM

Section 1 - Patient Information

Date of Birth :

Sex

MaleFemale

Section 2 – Parent / Guardian / Financially Responsible Party / Primary Insurance Subscriber

Date of Birth :

Section 3 – Medical Information

Date of Injury :

Was the injury work-related?

YesNo

Are you diabetic?

YesNo

If amputee, Amputation Date :

Amputation Side

RightleftBilateral

I certify that the information provided above is accurate and complete.

Date of Signature :

Sign here ( use the mouse or your finger on mobiles or tablets ) :

This form must be sent to:
—Please choose an option—San Mateo - CA (Jolene Freeman)Green Bay - WI (Lynn Chervenka or Marsha Holtzheimer)The Woodlands - TX (Norma Prieto)Lauderdale - FL (Lynn Chervenka or Marsha Holtzheimer)Boulder - CO (Stephanie Romero)

Please check that all information is completed and try to submit the form until you receive a successfully sent message, thanks.