CENTA - Appointment Request

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Patient Information Online Form

The form below is for patients who wish to submit their information online, electronically as an alternative to the traditional printed paperwork method.

Please complete the form in its entirety and then click the Submit Form button at the bottom to transmit your data to our offices.

Patient Information First Name: Last Name: DOB:
Gender:
Race: Ethnicity:
Address:
City: State: Zip:
Phone: Email:
Physician: Phone:
Pharmacy: Phone:
Other family members treated here:

Parent(s) / Legal Guardian Information Who has legal custody of patient:

If not biological/natural parents, court documents must be present at time of visit.

Mother Name: DOB:
Address:
City: State: Zip:
Home Ph: Mobile Ph:
Occupation: Employer: Work Address: Work Ph:

Father Name: DOB:
Address:
City: State: Zip:
Home Ph: Mobile Ph:
Occupation: Employer: Work Address: Work Ph:

Emergency Contacts Name: Relationship: Phone:

Name: Relationship: Phone:

Insurance Information Carrier: Policy #: Group #:
Claim's Address:
Phone: Co-Payment $: Deductible $:

Carrier: Policy #: Group #:
Claim's Address:
Phone: Co-Payment $: Deductible $:

Payment Agreement Terms
Payment is expected IN FULL at the time services are rendered by the person accompanying the child for treatment. If our office is a participating provider with your insurance carrier, all non-covered services, co-pays, and or deductibles will be collected at the time of each visit. Arrangements for anything other than full payment at the time of service must be made prior to your appointment. It is the responsibility of the guarantor to understand and accept the guidelines set up within the individual’s insurance plan. If you are unable to provide us with complete insurance information at the time of your visit you will be responsible for payment of services IN FULL. I understand that I am financially responsible for any balance not covered by my insurance carrier. I further understand and agree, that if I fail to make timely payments on my account, I will be responsible for any and all reasonable costs of collection, including filing fees as well as reasonable attorney’s fee.

By submitting this information online, I acknowledge that I have read and understand the office policy for payment and agree to the terms as stated.