General Patient Information



 
   
 
   

 
 

 

 

Spouse Information

 
 
 

In Case of Emergency

 

If the Patient is a Minor or Student

 
 

Insurance Information

 
 
   
   
 
 
 
 
 

Authorizations

 
(Electronically Signed)

   

I understand that if my Desert Kidney Associates financial account needs collection, all collection fees will be added to the original balance, including an annual interest charge of 10%.

 
(Electronically Signed)

   
(Electronically Signed)