New Patient Information Form

Kathleen L Behr MD

1125 E Sprice Ave - Suite 2007 - Fresno, CA93720
Phone: (559) 435-7546
  • Patient Information

  • Employment Information

  • Responsibility Party Information

  • Insurance Information

  • Spouse Information

  • Relative to Contact in Case of Emergency

  • Is Your Illness or Injury Related to the Following?

  • Consent to Treatment/Financial Responsibility and Assignment of Benefits

  • Accepted file types: jpg, tiff, png, pdf.
    Upload signature file.
  • Medical Health Questionaire

    Please answer all questions, checking either YES or NO
  • Add a new row
  • Add a new row

  • Please answer the following questions on a scale of 1 to 5 by marking the appropriate number:

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