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Mari K. Hayes, Ph.D.

Psychologist

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Registration Form

Patient's Name

Patient's Email

Patient's Address

Patient's Date of Birth

Patient's Phone

Are you the responsible party for the doctor's fees?

Patient's Employee Information:

Responsible Party:

Party Responsible for Fees (if other than the patient)

Relationship to Patient

Responsible Party's Phone

Responsible Party's Date of Birth

Responsible Party's Address

Responsible Party's Employer Information:

Emergency Contact:

Name of Emergency Contact

Emergency Contact Phone Number

Emergency Contact's Relationship to Patient

Please Sign:

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Date of Signature

Thanks for submitting!

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