GROUPON NEW PATIENT FORM

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

Step 1 of 4

If you are a new patient, uploading your Driver’s License/Government Issued Photo ID will ensure the check-in process for your first appointment will be as quick as possible.



INSTRUCTIONS

1. With your smartphone, take a picture of the front and back of your Photo ID and Insurance Card prior to starting this form.

2. To upload your images, click the “Choose a file” button and locate "Photo library" on the image on your phone.

3. Do not use the “Take Photo or Video” feature within the form.

4. To ensure your images upload properly, take the photos BEFORE you start the form. Do not use the “Take Photo” feature within the form. Except in SELFIE UPLOAD BUTTON

Contact our office at 510-792-4525 (Newark)

if you have any questions. Or ask the Receptionist to help fill up these forms while waiting for your appointment

NOTE: Your files are fully encrypted with HIPAA-compliant software to ensure security and privacy.

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