Patient Cover Sheet First Name *Last Name *Date of Birth *Street Address *City *State/Province *ZIP / Postal CodeHome PhoneMobile Phone *Email Address *OK to Contact via Email *Please select an optionYesNoDriver's License ID NoHealth Insurance ProviderInsurance ID NoGroup NoInsurance CardDrag and Drop (or) Choose FilesPlease upload photos of your insurance card (front and back)Referring or Primary PhysicianFirst NameLast NamePhoneFaxPharmacyName and Zip of PharmacyPhone NumberIn case of emergency, please contactI 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 incur a $75 fee. I have been informed by his office regarding this policy and agree to its terms and conditions. *I UnderstandSend Message