Patient Information

*First Name


*Middle Name


*Last Name


*Date of Birth


*Home Phone


*Cell Phone


*Work Phone


*Address 1


Address 2


*City


*State
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code


Email


*Social Security Number (no dashes)


*Sex
Select Male Female

*Marital Status
Select Married Single Divorced Widowed

Smoker
Select Yes No

*Employer Name


*Name of Primary Physician


*Physician/Provider that ordered this test or procedure

Emergency Contact Information

*First Name


*Last Name


Date of Birth (required if spouse)


*Address 1


Address 2


*City


*State
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code


*Home Phone


*Cell Phone


*Work Phone


*Relationship
Select Parent Spouse Other

(Complete this section if you have more than one emergency contact)

*First Name


*Last Name


Date of Birth (required if spouse)


*Address 1


Address 2


*City


*State
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code


*Home Phone


*Cell Phone


*Work Phone


*Relationship
Select Parent Spouse Other

Reason for Visit

*For which test/procedure are you scheduled?


Was this visit ordered due to an accident?
Select Yes No

Insurance Information

If you do not have health insurance, and would like to speak to a Financial Counselor regarding payment options, please call (812) 825-0894.

*Do you have?
Select Traditional Medicare Medicare Replacement Plan Neither

*Do you have Medicaid?
Select Yes No

*Name of Insurance Company


*Name of the Insured


*Relationship to Patient
Select Parent Spouse Other

*Insured's Date of Birth


*Insured's Social Security Number (no dashes)


*Insured's Employer


*Insurance ID#


*Group/Account #