Online Registration

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:
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

Fax:
Fill out this form, and then print it, sign it and fax it to 713-790-0527.

Online:
Fill out this form and press Go to Step 2. You DO NOT have to sign it because your e-mail address is your signature

Complete after you have made an appointment

Enter Your Patient Demographics

	Name (First/Last)			Home Phone
	Address			City, State, Zip
	Other Last Names			Age/Weight/Height
	Marital Status/DOB	- Select Below - Single Married Widowed Divorced		Race	- Select Below - Caucasian Black Hispanic Indian, A. Oriental Other
	Employer			Business Phone
	Occupation			Cell Phone

		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
	Now that your Personal Data is complete you must enter you Personal Medical History. If you elected to Mail or Fax your Personal Data then print and sign this form and press "Go To Step Two". If you elected to register Online then press "Go To Step Two".