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Pre-Registration Form

Contact Us > Patient Pre-registration Form

Fields marked with an * are required

A. PATIENT INFORMATION

 Cell-Phone
 Home Phone
 E-mail
 Text

Emergency Contact Details

Additional Contact Details

B. PERSON RESPONSIBLE FOR PAYMENT (IF PATIENT IS A CHILD, THE PERSON WHO HAS CUSTODY)

Check here if the person responsible is the same as the patient in section A:

C. HEALTH INSURANCE INFORMATION

PLEASE BRING ALL INSURANCE CARDS TO YOUR APPOINTMENT

D. SECONDARY INSURANCE INFORMATION

PLEASE BRING ALL INSURANCE CARDS TO YOUR APPOINTMENT

By checking this box, I agree that the information is accurate and that I am responsible for notifying Toledo Clinic of any changes.

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