Bernard L. Rosenfeld,
M.D., Ph.D.
7400 Fannin | Suite 910
Houston, Texas 77054
Phone: 713.790.0099
Toll: 866.790.0095 
Fax: 713.790.0527
E-mail:  
info@rosenfeldmd.com
 
By filling out this form you do not have to arrive 15 minutes early to fill out it in our office. This gives you the opportunity to fill out the form in the privacy of your own home, and gives you access to your medical records.
Mail: Fax: Online:
Fill out this form, and then print it,
sign it and mail it to:
Bernard L. Rosenfeld, M.D., Ph.D.
7400 Fannin, Suite 910
Houston, TX 77054 		Fill out this form, and then print it,
sign it and fax it to 713-790-0527.		 Fill out this form and press Submit
Form. You do not have to sign it
because your e-mail address is
your signature.
     
  Patient Name   Phone
Address City, State, Zip
Date of Birth Age
Marital Status Race
Employer Business Phone
Occupation    
 
    Spouse Data
Spouse's Name   Occupation
Employer Business Phone
 
    Person Responsible for Bill Data
Name (if other than above)   Phone
Address City, State Zip
Relationship    
 
    Nearest Relative Data (Not living with patient)
Nearest Relative   Phone
Relationship    
 
    Referral Data
Referred By   Phone
 
    Insurance Data
Insurance Company   Policy Number
Member Name Group Number
Employer Insurance Phone
Insurance Mailing Address City, State Zip
 
    Secondary Insurance Data
Insurance Company   Policy Number
Member Name Group Number
Employer Insurance Phone
Insurance Mailing Address City, State Zip
 
    Authorization to Release Information and to Pay Benefits
  I hereby authorize Bernard L. Rosenfeld, M.D., Ph.D. who has treated or attended me or my dependents
to furnish any medical information requested. In consideration for services rendered, I hereby transfer and assign to Dr. Rosenfeld who has treated me or my dependent, and benefits of insurance that I may have.
I am responsible for paying non-covered services. A photocopy of this authorization shall be considered
as effective and valid as the original.
     
  Patient SSN   Spouse's SSN
Medicare Number Medicaid Number
Texas Driver's License Signature ________________
       
  Do you have an appointment? Yes No
If yes, when?  
If no, would you like for us to contact you regarding an appointment? Yes No
  How would you like to be contacted?
How did you find this web site?
   
    Read and Sign

I acknowledge that the above information is correct and complete.

Your signature _____________________________________________
Today's date _____________________________________________
E-Mail Address
   
    Instructions
  1. Now that your Personal Data is complete you must enter you Personal Medical History.
  2. If you elected to Mail or Fax your Personal Data then print and sign this form and press "Go To Step Two".
  3. If you elected to register Online then press "Go To Step Two".
   
   
 
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