This document contains fields for collecting a patient's personal information such as name, contact details, date of birth, insurance information, emergency contacts, and a statement authorizing Dr. Roy Michael Stefanik to provide medical services and for the patient to pay for those services. The patient signs and dates the bottom of the form to acknowledge their agreement.

1. Roy Michael Stefanik, DO
Psychiatry
Last Name First Name Middle Initial
Street Address City State Zip Code
Home Phone May we call and/or leave a message at your home number? Yes  No 
Work Phone May we call and/or leave a message at your work number? Yes  No 
Cell Phone May we call and/or leave a message at your cell phone number? Yes  No 
E-Mail Address
Date of Birth Marital Status Sex
Referred By Allergies
Employer Occupation
Spouse’s Name Spouse’s Occupation
Person to Notify in the Event of an Emergency Relationship Phone
Patient/Subscriber Authorization Statement
I hereby agree to pay Dr. Roy Michael Stefanik for his services at the time they are rendered. Dr. Stefanik will provide
me with a comprehensive statement which I can submit to my insurance company.
Signature of Patient Date
11/10/09