Patient Registration Information

PLEASE FILL OUT ALL BLANKS – IF LEFT BLANK WE WILL ASK YOU TO FILL IT OUT. IF IT DOES NOT APPLY TO YOU, PLEASE PUT (N/A). WE NEED ALL INFORMATION FOR BILLING PURPOSES.

Date

Social Security #

Date of Birth

Marital Status (Please Circle One)

S M D W

Sex

Male Female

First Name

M.I

Last Name

Address

City

State

Zip

Apartment or Suite #

Home#

Mobile#

Ethnicity

Race

Preferred Language

Email Address

(Please provide email or mobile number for courtesy appointment reminder)

Would you like to create a Patient Portal with this Email?

Yes No

Employment Status (Please Circle One)

Employed Unemployed Self Employed Student Retired Disabled

Employer’s/School Name

Phone

Extension

Employer’s or School's Address

City

State

Zip

Emergency Contact

(Please indicate a friend or relative not living at the same address that we may contact)

Emergency Contact

Phone

Relationship

Date of Birth

Responsible Party and Billing Information

Patient's Parent or Legal Guardian if the patient is a minor under 18 years of age. This is the person responsible for the patient.

First Name

M.I.

Last Name

Date of Birth

Social Security #

Sex

Male Female

Phone

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

By initialing here I verify the all information above is correct to the best of my knowledge:

Insurance Information: (Please provide all insurance cards and picture I.D. to Front Desk Clerk to copy/scan to your file). Your appointment will be rescheduled if you do not have appropriate ID.

Primary Insurance

Insurance Plan

Insurance Phone

Address

City

State

Zip

Insurance ID#

Group#

Patient Relationship to the Subscriber (Circle One)

Self Spouse Child Other

Other Specification

Subscriber Last Name

First Name

Date of Birth

Social Security #

Sex

Male Female

Secondary Insurance

Insurance Plan

Insurance Phone

Address

City

State

Zip

Insurance ID#

Group#

Patient Relationship to Insured Party (Circle One)

Self Spouse Child Other

Other Specification

Subscriber Last Name

First Name

Date of Birth

Social Security #

Sex

Male Female

Please provide us with your preferred Pharmacy Information.

Name of Pharmacy

Pharmacy Phone

Pharmacy Address

City

State

Zip

Referral Information

Obstetrician

Phone

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

I fully understand and acknowledge that Fort Worth Perinatal Associates, P.A. is a specialty practice which I have been referred to by my primary OB physician, on a consultation basis only. My Obstetrician will continue to care for me during my pregnancy and will be delivering my baby. I also understand that it is vital for me to continue seeing my Obstetrician for regularly scheduled appointments, even if I have an appointment with Fort Worth Perinatal Associates, P.A. the same day or same week.

By initialing here I verify that all information above is correct to the best of my knowledge

Your information will be encrypted.