Patient Registration Form

Appointment Time:

Provider:

Patient #:

Name

Marital Status:

Date of Birth:

Age:

Sex:

Male Female Other

Full Time Student:

Yes No

Race/Ethnicity:

SS #:

Home Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Employer:

Work Phone:

Preferred Phone #:

Home Work Cell Phone

Email:

How would you like reminders for your appointment?

Voice

Text

No reminder

May we leave personal medical information on your personal answering machine/voice mail?

Yes No

If Patient is Minor

Legal Guardian (Last Name, First Name MI):

Date of Birth:

Address:

City:

State:

Zip:

Phone:

Primary Physician (Last Name, First Name):

Phone:

Referring Physician (Last Name, First Name):

Phone:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent/ Legal Guardian, if minor:

Date:

Additional Information

Patient #:

Patient Name:

Today's Date:

Are you currently covered by TennCare?

Yes No

Have you applied for TennCare within the last year?

Yes No

Insurance Coverage - Primary

Insurance Company Name:

Member ID#

Group #

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

Policy Holder Social Security #:

Policy Holder Place of Employment:

Patient Relationship to Policy Holder:

Self Spouse Child Other

If other, Please Specify Here:

Insurance Coverage - Secondary

Insurance Company Name:

Member ID#

Group #

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

Policy Holder Social Security #:

Policy Holder Place of Employment:

Patient Relationship to Policy Holder:

Self Spouse Child Other

If other, Please Specify Here:

We need the name of someone we can contact in the event of an emergency as well as release medical information about your condition. Please list below.

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

PLEASE NOTE: If you are the PARENT OF A MINOR CHILD, you should be listed here as well as anyone else we may contact.

Pharmacy:

Phone #:

Please present insurance card(s) and photo ID to the receptionist to be scanned.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent/Legal Guardian, if minor:

Date:

Your information will be encrypted.