PATIENT REGISTRATION FORM

STEP 1 / 6

*Primary Care Physician Phone # Referred By Phone # How did you hear about our practice ?

PATIENT INFORMATION

* Required fields. ** Please enter only the last 4 digits of Social Security Number.

*Patient Name **SSN *Date of Birth *Gender M F

*Address Apt# *City, State, Zip

*Home Phone# *Cell / Work Phone# Email

*Race African American Hispanic or Latino American Indian Asian Native Hawaiian/Pacific Islander White

*Preferred Language

*Marital Status S M D W   Employer *Occupation

Employer's Address City, State, Zip

(If patient is a minor (Under 18 or full time student)

Guarantor SSN Birthdate Gender M F

Guarantor Address City, State, Zip

(If different from patient)

*Emergency Contact *Phone# *Relationship to patient

Spouse Name

INSURANCE INFORMATION

*Primary Insurance *Policy# Group# Address City, State, Zip *Insured Name *Date of Birth *Phone# *Relationship to patient

Secondary Insurance Policy# Group# Address City, State, Zip Insured Name Birthdate Phone# Relationship to patient

Do you have a vision policy? Name Insured Policy#

Phone#

I certify that the above information is correct and hereby authorize the release of medical information to my insurance company and/or to my referring physician. I assign to the physician(s) all payments for services rendered to my dependents or me. A copy of this authorization may be used in place of original. Insurance will be filed if the physician(s) are covered under my plan. It is my responsibility to obtain a referral if required. I understand that I will be responsible for all non-covered service, co-payments and deductibles. I hereby voluntarily consent to treatment at his/her office and authorize such treatments, examinations, medications. Co Payment is due at time of service.

*Enter Your Name Date