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New Client Information for Dr. Abrams
This form is to be completed by the individual seeking care from Dr. Abrams; if that individual is under the age of 18, the form needs to be completed by the parent or guardian
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Name:
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Email:
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Address:
Occupation:
City/State/Zip:
Work Phone:
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Home Phone:
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Cell Phone:
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SS#:
Date Of Birth:
Referred By:
Insurance Company:
Plan#:
Group#:
Name Of Insured:
Secondary Insurance:
Plan#:
Group#:
Are you currently under the care of a physician or taking medications? (if so please list medication and prescribed medications)
I understand that all conversations and communications with Dr. Abrams are confidential except for reports of child abuse and threats of violence against a specific individual. Dr. Abrams will keep all of my records secure and confidential. I give Dr. Abrams permission to bill my insurance carrier for services he has provided to me. Should these payments come to me, I understand that they are due to Dr. Abrams. I understand that Dr. Abrams requires 24 hours’ notice to cancel an appointment, I agree to pay $50.00 if I fail to provide this.
