Resurgens Hand Center

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Appointment Request (Existing Patient)

This form is for existing patients only. If you are a new patient, use the appointment request form for new patients.

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Which office would you like to visit?

Personal Information

First Middle Initial Last Address City State Zip Daytime Phone Evening Phone Cell Phone Social Security # (last 4 digits) DOB Email Address

Appointment Information

Physician Preference Preferred Time of Day Preferred Date of Appointment Insurance Company If Other, specify: Reason for Visit If Other, specify: Is this visit work-related? Yes No Is this visit auto-related? Yes No Has your insurance changed since your last visit? Yes No If yes, please list new provider

I understand that Resurgens Orthopaedics cannot guarantee privacy for e-mail communications over the internet, other than website submissions from their official website, www.resurgens.com. I understand and accept this risk, and thus, will allow Resurgens Orthopaedics to communicate my protected health information using my personal e-mail address listed above.

Resurgens Orthopaedics

Greater Atlanta's Premier Hand Center

Resurgens Hand Center

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Appointment Request (Existing Patient)