Fuad Afzal, MD
P.O.Box 952951
Lake Mary, FL 32795
Phone: 407-896-1789 Fax: 407-896-1735
www.midfloridakidney.com

Patient Registration Form

 Patient Last Name  Patient First Name
 Date of Birth  Social Security Number
 Marital Status  Address
 Home Phone  Cell Phone
 Work Phone  Email Address
 Emergency Contact Name  Emergency Contact Phone
 Employer  
Insurance Company name and policy number
Primary
 Insurance Company name and policy number
Secondary
 If you are covered under the policy of a spouse, partner, parent, or legal guardian, please tell us about them:  
 Name  Social Security Number
 Home Phone  Cell Phone
 Work Phone  Email Address

Consent to Treat:
I (or my legal guardian or parent) authorizes Mid-Florida Kidney and Hypertension Care to provide medical care to me.

Assignment of Benefits:
I understand that I am financially responsible for all charges.

I hereby authorize the release of information necessary to secure the payment of benefits, and assign any insurance or other third-party benefits for health care services received to Mid-Florida Kidney and Hypertension Care. If these benefits are not assigned to Mid-Florida Kidney and Hypertension Care, I agree to forward to Mid-Florida Kidney and Hypertension Care all benefits immediately upon receipt.

I have read and understand the information outlined above.

Signature of the Patient/Legal Guardian: _______________________ Date:___________