Registration — Raul Mandler, MD: Board-Certified in Neurology

Registration Form

First Name

Middle Name

Last Name

Gender

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Emergency Contact Name

First Name

Last Name

Relationship to Patient

Emergency Contact Phone Number

Primary Insurance: Carrier Name

Please provide the name of your PRIMARY insurance carrier

Primary: Name of Policyholder

Primary: Name of Insured

Primary: Member ID #

Primary: Group/Plan #

Secondary Insurance: Carrier Name

Please provide the name of your SECONDARY insurance carrier, if applicable.

Secondary Insurance: Name of Insured

Secondary: Member ID #

Secondary: Group/Plan #