Patient Registration Form

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Click on the following link to open the registration form in a new browser window. You can then print it.
 
Patient-Registration Form
 

           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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