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