Complete this section if someone other than the patient is financially responsible.

Please list all current Medications

Prescriptions

Please list any non-prescription medications or substances you are currently taking here.

Social History

Responsible Party Insurance Information

I, certify that the above information is true and correct to the best of my knowledge.  I will notify you of any changes to the above information. I authorize the release of any medical information neccessary to process an insurance claim.