Patient Registration Form

PATIENT INFORMATION

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

EXT:

Cellular

Preferred Name:

Sex

Male Female

Marital Status:

Married Single Divorced Separated Widowed

Birth Date:

Age

Soc Sec #:

Driver's License #:

Email Address:

Would you like to receive appointment reminders via email?

Yes No

Employment Status:

Full Time Part Time Retired

College Student Status:

Full Time Part Time

Name and Address of Employer:

Name and Address of College:

Spouse's Name:

Soc Sec #:

Birth Date:

If spouse employed, Name and Address of Employer

Do you have any immediate medical problems?

When was your last visit to your primary physician and what was it for?

If Patient is a Child or Dependent, Names and Addresses of Parents or Guardians:

Parent/Guardian #1

Address:

Phone:

Parent/Guardian #2

Address:

Phone:

RESPONSIBLE PARTY, IF OTHER THAN PATIENT (financial)

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

EXT:

Cellular:

Birth Date:

Age:

Soc Sec #:

Driver’s License #:

Employer Name and Address:

Relationship to Patient:

PRIMARY MEDICAL INSURANCE (if any)

Upload Photo of Insurance Card

Add file

Please upload a file

Name of Insured:

Birth Date:

Soc Sec #:

Patient’s Relationship to Insured:

Self Spouse Child Other

If relationship selected is other, kindly explain here:

Employer Name and Address:

Name of Insurance Company:

Please provide us with your insurance card for scanning

SECONDARY INSURANCE (if any)

Name of Insured:

Birth Date:

Soc Sec #:

Patient’s Relationship to Insured:

Self Spouse Child Other

If relationship selected is other, kindly explain here:

Employer Name and Address:

Name of Insurance Company

Please provide us with your insurance card for scanning.

I certify that the information above is true and correct to the best of my knowledge and belief. I authorize my insurance company to pay directly to the medical office, insurance benefits otherwise payable to me. I understand I am responsible for all co-pays, deductibles, co-insurance balances. I understand and agree that my bill for services rendered is due and payable at the time of service and that I am ultimately responsible for any unpaid balances.

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.

Mark the areas on the image where you are experiencing symptoms

Signature

Date:

We truly appreciate referrals to our practice. Is there anyone we might thank for referring you to our office?

Name and Address

If there is anything we can do to make your visits more comfortable, please do not hesitate to tell us. Thank you for choosing our office!

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