Sample Medical Registration Form

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QUINNIPIAC PHYSICAL THERAPY
& SPORTS MEDICINE, P.C.
Today’s Date
REGISTRATION FORM
PATIENT INFORMATION
Last Name
First Name
Middle Initial
Sex
Birthdate
☐Male☐ Female
Marital Status
Soc. Sec. #
Home Phone #
Cell Phone #
☐Single ☐Mar☐ Div ☐Sep ☐Wid
Street address
City
State
Zip Code
Email address:
Appointment Reminder
☐ Voice
☐Text
Occupation
Employer (with address)
Employer Phone #
Primary Care Physician
Address
MD Phone #
IN CASE OF EMERGENCY
Name of friend or relative:
Relationship to patient:
Home phone #
Cell phone #
INSURANCE INFORMATION
(Please give your insurance card(s) to the receptionist)
Primary Insurance
Policy #
Subscriber’s Name
Subscriber’s Social Security #
Birthdate:
Relationship to subscriber:
☐Self ☐Spouse ☐Child ☐Other
Secondary insurance
Policy #
Subscriber’s Name
Subscriber’s Social Security #
Birthdate:
Patient’s relationship to subscriber:
☐Self ☐Spouse ☐Child ☐Other
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to
Quinnipiac Physical Therapy & Sports Medicine, P.C. I understand that I am financially responsible for any balance. I
also authorize Quinnipiac Physical Therapy & Sports Medicine, P.C. to release any information required to process my
claims.
______________________________________
_________________________________________
Parent/Guardian signature
Date
Above information reviewed with no changes:
Initial_____Date_____
Initial_____Date_____
Initial_____Date_______
Initial_____Date_______

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