Patient First Name Patient Last Name Date of Birth (MM/DD/YYYY) Last 4 numbers of your Social Security number (if applicable)
Address (Please include Apt/Suite Number) City State
Zipcode Home Phone Number Cellphone / Pager E-mail
Source of Referral      
I understand that Dr. Wollschlaeger does not accept certain insurance assignments and that I may be financially responsible for all charges.
I, the patient or guarantor, certify that the information on this form is true to the best of my knowledge.
I accept responsability for the medical charges incurred by my person and agree to pay all bills at the time of the service.
In the event of default, I agree to pay all costs of collection, and reasonable attorney's fees.
I further agree that a photocopy of this agreement shall be valid as the original.
I hereby authorize Dr. Wollschlaeger to furnish to insurance companies or their representativesinformation regarding my illness and treatment. All medical information is strictly confidential and can only be released to a third party with my written concern.

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Aventura Family Health Center - 909 North Miami Beach Blvd, Suite 403, North Miami Beach, FL 33162
Tel: 305-940-8717 / Fax: 305-402-2989