Patient Registration Form

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Patient-Registration

           PATIENT REGISTRATION FORM   

 Doctor___________________              P #______________________   

PATIENT INFORMATION

Patient Name: _______________________________________________________________________________                                                Last                                                                         First                                                  Middle Initial

Address: ______________________________________________________________________________________

Street                                                                       City                                          State            Zip Code

Home Phone: ____________________ Work Phone: ___________________ Cell Phone: _____________________

E-Mail Address: ________________________________________________________________________________

Date of Birth: ____________________  Age: __________  Sex “ M “ F  Social Security #: ___________________ “

Single  “ Married  “ Widowed  “ Separated  “ Divorced – Spouses Name: ________________________________

Race: “ White “ African American “ American Indian “ Asian “ Hawaiian/Pacific Is. “ Declined Ethnicity: “ Hispanic “ Non-Hispanic Employer:_____________________________________________________________________________________

Name and Address of Your Employer Pharmacy: __________________________________________

Pharmacy Phone #: __________________________

Name / City Whom may we thank for referring you? _____________________________________________________________

In case of emergency whom should we notify?_________________________________________________________

Relation to Patient: _______________ Daytime Phone # ________________ Evening Phone # __________________

GUARANTOR INFORMATION

Patient Information Party Responsible: ______________________________________Relation to Patient: _________________________ Address: ___________________________________________________Phone #: ____________________________ If different from Patient

PRIMARY INSURANCE

Please present your Insurance ID card and Driver’s License to receptionist for photocopying Insurance Company: __________________________ ID #: ______________________________________________

Primary Subscriber: _______________________________Date of Birth: ________ Social Security #_____________

SECONDARY INSURANCE

Is Patient covered by additional insurance?   “ Yes  “ No Insurance Company: __________________________

ID #: ______________________________________________ Primary Subscriber: _____________________________

Date of Birth: _______ Social Security #: _______________

ADDITIONAL INFORMATION

Was this condition related to a work injury?                                      “  Yes  “  No

Was the injury reported to your Employer?                                        “  Yes  “  No

Was this condition related to a motor vehicle accident?                    “  Yes  “  No

PAYMENT IS EXPECTED AS SERVICES ARE RENDERED

I hereby authorize the release of any medical information necessary in the processing of my insurance claims.  I certify that the above information is complete and correct to the best of my knowledge.

Signature: _______________________________________________________ Date: ________________

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