All professional services rendered are charged to the patient. Necessary forms will be completed to help you expedite insurance carrier reimbursements. However, the patient is responsible for all fees, regardless of insurance coverage. You are required to pay at the time of the service, unless other arrangements have been made in advance with our office manager. We will file your insurance when surgery is involved.

By checking the box below, I hereby authorize Ian J. Reynolds, M.D., to furnish information to the insurace carrier/referring physician concering my illness and treatment and I hereby assign to the physician all insurance payments for medical services rendered to myself or my dependents (when filed by the physician's office). I also authorize medical information to be faxed upon request.

I understand that I am responsible for any and all amounts not covered by my insurance company.

Check Box Here

We’re sure you’re eager to set up the appointment you’ve been needing, so don’t hesitate to call. Also, we’d appreciate it if you’d take the time to fill out our Patient Information form below.

In order to expedite your waiting time, download, print and fill out the following forms and bring with you on your visit.

Click the thumbnail or click here to download the forms.

Patient Information Form
Please remember to present proof of insurance, Medicare and/or Medicaid. Payment is expected at the time of service unless special arrangements are made.

First Name

M.I.

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

E-mail Address

Phone

Bold = Required field

Date of Birth

Marital Status

Age

Sex

Drivers License #

Driver License State

Social Security # (Optional)

Student

Employer

Patient's Employer

Employer

Occupation

Address

Phone

Patient Information

Injury or Complaint

How Did Injury Occur?

Referred By

Did You Get Hurt On The Job?

Auto Accident?

Date Injured

Do You Have An Attorney?

Attorney's Name

Patient's Spouse/Parent/Guardian

Name

Relationship

Phone

Address

Employer

Employer Address

Social Security # (Optional)

Emergency Contact/Nearest Relative

Name

Address

Phone

Insurance Information

Insurance Company

Insured Person

Insurance Company Address

Insurance Phone

Policy #

Group #

Subscriber #

Employer

Secondary Insurance

Insurance Company

Insured Person

Insurance Company Address

Insurance Phone

Policy #

Group #

Subscriber #

Employer