New Patient Registration

PATIENT INFORMATION

LAST NAME:

FIRST NAME:

MIDDLE NAME:

NICKNAME:

ADDRESS:

CITY:

STATE:

ZIP:

SEX:

MALE FEMALE

PHONE:

DOB:

PARENT/GUARDIAN INFORMATION

PARENT 1:

DOB:

ADDRESS: (IF DIFFERENT THAN CHILD'S):

EMAIL:

PHONE:

EMPLOYER:

OCCUPATION:

WORK PHONE:

PARENT 2:

DOB:

ADDRESS: (IF DIFFERENT THAN CHILD'S):

EMAIL:

PHONE:

EMPLOYER:

OCCUPATION:

WORK PHONE:

INSURANCE INFORMATION

PRIMARY POLICY

INSURANCE COMPANY:

POLICY#

GROUP#

ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

NAME OF INSURED:

RELATIONSHIP:

PREFERRED METHOD OF CONTACT (GENERAL MESSAGES, REMINDERS)

GENERAL:

EMAIL

PHONE

TEXT

REMINDERS:

EMAIL

PHONE

TEXT

EMERGENCY CONTACT

NAME:

RELATIONSHIP:

PHONE:

PHARMACY INFORMATION

PREFERRED PHARMACY:

ADDRESS:

PHONE:

ETHNICITY

UNKNOWN HISPANIC OR LATINO NOT HISPANIC OR LATINO DECLINE TO SPECIFY

LANGUAGE(S)

RACE

AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN NATIVE HAWAIIAN OR PACIFIC ISLANDER WHITE DECLINE TO SPECIFY OTHER