Joseph P. Laukaitis, M.D.

Registration Form

NAME:  __________________________________________________________       Date:   ____________
                                 Last              First              Middle


AGE: _____ 
    DATE OF BIRTH:   ____________________     SOC. SEC.#  _______________________ 
                                                                    Mo/Day/Yr

HOME ADDRESS:  _____________________________________________________________________ 

__________________________________________   ZIP ________    HOME TEL-(     )-  ____________

OCCUPATION: ________________________________________   WORK TEL-(     )-  ______________

EMPLOYED BY: _______________________________________   CELL TEL-(     )-  ______________

BUSINESS ADDRESS: _______________________________________________________ ZIP ______

SPOUSE’S NAME: __________________________________________  WORK TEL-(     )- __________

SPOUSE’S OCCUPATION: ____________________________

PERSON TO CONTACT IN CASE OF EMERGENCY (OTHER THAN SPOUSE):

NAME: _____________________________________________________  TEL -(     ) ______________

ADDRESS: ________________________________________________________________ ZIP_______ 

RELATIONSHIP: ___________________        REFERRED BY: _________________________________

DO YOU HAVE HEALTH INSURANCE? _____ YES  _____  NO

A. BLUE CROSS/BLUE SHIELD                             B. OTHER INSURANCE:

IDENTIFICATION #  _________________  COMPANY: ____________________

GROUP # ___________________  POLICY# ________________ MEDICARE  ID#  _______________

I authorize the release of any medical information necessary to process this claim and I authorize payment of
medical benefits to physician for services rendered.

SIGNATURE: ________________________________