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Patient Cover Sheet

First Name *

Last Name *

Date of Birth *

Street Address *

City *

State/Province *

ZIP / Postal Code

Home Phone

Mobile Phone *

Email Address *

OK to Contact via Email *Please select an optionYesNo

Health Insurance Provider

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Insurance Card

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Please upload photos of your insurance card (front and back)

Referring or Primary Physician

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First Name

Last Name

Phone

Fax

Pharmacy

Name and Zip of Pharmacy

Phone Number

In case of emergency, please contact

I understand that Dr. Petros Efthimiou is an OUT OF NETWORK physician and all charges are expected to be paid at or before the time of service. Dr Petros Efthimiou’s office is not responsible for the amount of reimbursement from my insurance company. No-shows or cancellations within 24 hours from the time of the appointment will result in forfeiture of prepaid visit fee. I have been informed by his office regarding this policy and agree to its terms and conditions. *I Understand

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