<p> NEW PATIENT QUESTIONNAIRE</p><p>Patient Name ______Phone ______</p><p>Mailing Address ______City, State, Zip______Email:______</p><p>Street Address (if different than above) ______TX Drivers License ______</p><p>County of Residence ______DOB ______Social Security #:______</p><p>Current Employer ______Occupation ______Phone ______</p><p>In case of emergency, notify: ______Phone:______</p><p>Primary Subscriber: ______DOB: ______</p><p>Subscribers Current Employer: ______Relationship to Patient: ______</p><p>If this is a WORKERS COMPENSATION injury, complete this portion:</p><p>Employer at time of injury ______Phone______</p><p>Date of Injury______Area to be treated______</p><p>If NOT work related, complete this portion:</p><p>IS your referral to our office related to a SPECIFIC INJURY OR ACCIDENT? ______</p><p>If YES, date of injury or accident: ______</p><p>Brief description of injury/accident: ______</p><p>If a minor, name of presenting PARENT/GUARDIAN: ______Daytime Phone ______</p><p>Name of Guarantor*:______*(Please note: RRR will NOT be a party to 3rd party custodial agreements, i.e., divorce decrees. We will require payment from the presenting parent/guardian).</p><p>Address of Guarantor: ______</p><p>Social Security #______Texas Drivers #______DOB: ______</p><p>Please read BEFORE SIGNING: I hereby accept full responsibility for any and all charges not covered or reimbursed by my insurance carrier or any other third party payer to Round Rock REHAB, regardless of reason. I AGREE AND UNDERSTAND that I am fully responsible for, and will pay, all amounts not paid by insurance within thirty (30) days of being billed by Round Rock REHAB. I UNDERSTAND AND AGREE that in the event Round Rock REHAB files any claims against balances due in Small Claims Court, or with any other source to try to collect balances due, I/we will be required to pay any handling, postage, and/or court fees. I AUTHORIZE the release of any information necessary to process any claim on my behalf. I AUTHORIZE AND REQUEST THAT ANY AND ALL BENEFITS PAYABLE BE PAID DIRECTLY AND SOLELY TO ROUND ROCK REHAB.</p><p>______Guarantor/Patient Signature Date</p><p>Round Rock Rehab, P.C. 16020 Park Valley Drive Round Rock, TX 78681 Phone: 512.388.1448 Fax: 512.388.7854 Web: www.roundrockrehab.com Email: [email protected] RRR006_v05.2012</p>