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    Patient Registration

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    aqil 113

    Copyright:

    © All Rights Reserved
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    Patient Registration

    Uploaded by

    aqil 113
    3 views3 pages

    Original Title

    PATIENT REGISTRATION

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3 views3 pages

    Patient Registration

    Uploaded by

    aqil 113

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 3

    PATIENT REGISTRATION

    Please Print

    Patient Name (First, Middle, Last): _____________________________________________________________

    Date of Birth: ______________________ Social Security Number: _________________________________

    Ethnicity: Race:
    o Hispanic o White
    o Non-Hispanic o Black
    o Asian
    o Hawaiian
    o Other _____________

    Sex at birth: Gender Identity:


    o Male o Male
    o Female o Female
    o Other _____________ o Transgender Female
    o Decline to answer o Transgender Male
    o Gender Queer
    o Other _____________
    o Decline to answer

    Preferred Pronouns:
    o He/him/his
    o She/her/hers
    o They/them/theirs
    o Other _____________

    Home Address: ____________________________________________________________________________

    City, State, Zip: ____________________________________________________________________________

    Who can we thank for referring you to us? ______________________________________________________


    Patient Name (First, Middle, Last): _____________________________________________________________

    Preferred Phone Number: ______________________ Alternate Phone Number: ______________________


    Ok to leave message? Ok to leave message?
    o Yes o Yes
    o No o No

    Email Address: ______________________________ Emergency Contact Name: ____________________


    Would you like to join our portal?
    o Yes Relationship: _______________________________
    o No
    Phone Number: _____________________________

    Employer: _________________________________

    Job Title: __________________________________

    Insurance Information

    Primary Insurance Secondary Insurance


    Company Name: Company Name:
    Address: Address:
    City, State, Zip: City, State, Zip:
    Phone: Phone:
    Insured’s Name: Insured’s Name:
    Relationship to Patient: Relationship to Patient:
    Insured’s Birth Date: Insured’s Birth Date:
    ID Number: ID Number:
    Group Number: Group Number:

    Credit Card/HSA Card Number (to keep on file for co-pays, deductibles, outstanding balances):

    Number: _________________________________________________ Expiration Date: _________________

    Name on Card: ____________________________________________ Security Code: __________________

    **A copy of your state issued photo identification card or driver’s license is required. **

    I hereby authorize payments of medical benefits directly to the physician. I also understand I am responsible
    for any portion of my bill not covered by my insurance company. I hereby release the information for insurance
    claim purposes. I have read and understand all of the above and hereby state that the information is correct to
    the best of my knowledge.

    Patient or Parent/Guardian Signature: _________________________________ Date: ___________________

    Print Name: _______________________________________________________________________________


    Relationship to Patient: ______________________________________________________________________

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