Registration Form

Today’s Date

PCP

Chart No#

PATIENT INFORMATION

Patient’s Last Name

First

Middle

Date of Birth

Age

Sex

Male Female

Street Address

City

State

Zip

SSN

Driver’s License No#

State

Status

Single Married Divorced Widowed

Occupation

Patient’s Employer

Employer’s Tele No#

Employer’s Address

City

State

Zip

Patient’s HOME No#

Patient’s CELL No#

Patient’s WORK No#

Patient’s Email

If married, may we release medical information to your spouse?

Yes No

Spouse’s Last Name

First

Middle

Spouse’s CELL No#

Spouse’s WORK No#

PRIMARY INSURANCE INFORMATION

Name of Policy Holder/Subscriber

Policy Holder’s Date of Birth

SSN of Policy Holder/Subscriber

Policy Effective Date

Policy Holder/Subscriber’s Relationship to Patient

Sex

Male Female

Policy Holder/Subscriber’s Address (if different than patient’s)

Policy Holder/Subscriber’s Address

City

State

Zip

Group No#

Policy ID No#

Group Employer

Insurance Co. Name

Type

Medicare

PPO

POS

HMO

Other

Copay Amount

Insurance Co. Billing Address

City

State

Zip

SECONDARY INSURANCE INFORMATION

Name of Policy Holder/Subscriber

Policy Holder’s Date of Birth

SSN of Policy Holder/Subscriber

Policy Effective Date

Policy Holder/Subscriber’s Relation to Patient

Sex

Male Female

Policy Holder/Subscriber’s Address (if different than patient’s)

Policy Holder/Subscriber’s Address

City

State

Zip

Group No#

Policy ID No#

Group Employer

Insurance Co. Name

Type

Medicare

PPO

POS

HMO

⁪Other

Other

Copay Amount

Insurance Co. Billing Address

City

State

Zip

Emergency Contact Information

Name of Emergency Contact

Relationship

Address

Telephone

City

State

Zip

Is Orchard Medical Center, S.C. Authorized to Release Information to this Person?

Yes No

DISCLAIMER: 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.

Patient Signature

Date

Your information will be encrypted.