Sample Patient Registration Form
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1
2PATIENT REGISTRATION FORM
**Today’s Date: ________________________
Clinic Name: _______________________________________
PATIENT INFORMATION: (Please use full legal name, no nicknames)
*Last Name: _____________________________________ *First Name: ___________________________________ Middle Initial: ____________
*Address: _________________________________________________________________________________________________________________
City: ____________________________________________
State: ____________________________
Zip: ______________________
Home Phone #: (________) ________-_______________
*Social Security #: __________________________________________________
*Date of Birth: ____________________ Age: _________
*Sex: _______ Marital Status: ____________ Drivers Lic#: ______________
*Employer Name and Address: _______________________________________________________________________________________________
_______________________________________________________________________ Work Phone #: (________) ____________-_____________
E-mail Address: _________________________________________________________ Cell Phone #: (________) ____________-_____________
Emergency Contact Name: _______________________________________________ Emerg Phone #: (________) ___________-_____________
Please tell us how you heard about us: ________________________________Referred by___________________________________
GUARANTOR INFORMATION: (List person or insured name responsible for bill - use full legal name, no nicknames)
*Relationship of Guarantor to Patient:
Self _____
Spouse _____
Parent ______
Other _____________________________
*Last Name: ___________________________________ *First Name: ___________________________________ Middle Initial: _____________
*Address: _________________________________________________________________________________________________________________
City: _____________________________________________
State: ____________________________
Zip: ______________________
Home Phone #: (__________) ______________-_____________________
*Social Security #: __________________________________________
*Date of Birth: _________________________ Age: ________________________
*Sex:
Female _______
Male ________
*Employer Name and Address: _______________________________________________________________________________________________
__________________________________________________________________________
Work Phone #: (________)_________-__________
INSURANCE INFORMATION: (Please allow receptionist to photocopy your insurance ID cards)
IF SOMEONE OTHER THAN PATIENT IS THE INSURED PARTY, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS
PRIMARY INSURANCE:
Plan Name : __________________________________________
*Insured’s Name: ___________________________________
Insured’s Social Security #: _____________________________
*Insured’s Date of Birth: ____________________________
*Policy / ID #: _________________________________ *Group #: ________________________ Eff Date: ___________________
Claims Address & Phone: _______________________________________________________________________________________
SECONDARY INSURANCE:
Plan Name : __________________________________________
*Insured’s Name: ___________________________________
*Insured’s Social Security #: _____________________________
*Insured’s Date of Birth: ____________________________
*Policy / ID #: _________________________________ *Group #: ________________________ * Eff Date: ___________________
Claims Address & Phone: _______________________________________________________________________________________
*REQUIRED FIELDS-PLEASE COMPLETE FOR BILLING.
*ATTACH COPY OF INSURANCE CARDS.
Please read and sign back of form.
Confidential Proprietary Information
New Pt Reg Form Dec 2004
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Parent category: Medical