Patient Registration Form

Patient Information

Guarantor Information

Emergency Contact Information

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Insurance Information

*Southwest Shoulder, Elbow and Hand does not bill third-party liability.

Workers' Comp Information

Privacy Policy

Southwest Shoulder, Elbow & Hand Center, P.C. and each member of our staff strongly believe in protecting the confidentiality and security of information we collect about you. Your personal information will only be used to communicate with your other physician(s) or to help procure appropriate payment from your insurance company. By signing below, I acknowledge a complete Notice of Privacy Policy has been made available to me.

I acknowledge it is my responsibility to notify Southwest Shoulder, Elbow & Hand Center, P.C. of changes to any of my insurance(s) including additions, terminations and/or enrollment at the time the event occurs. Otherwise, I understand I may be responsible for any charges that occurred during this time.

ALL INFORMATION THAT I HAVE PROVIDED IS CURRENT AND ACCURATE TO THE BEST OF MY KNOWLEDGE