Registration Form (Medical)

ADVERTISEMENT

E.A. HAWSE HEALTH CENTER
REGISTRATION FORM
Medical
(Please Print)
Today’s Date:
NEW:
UPDATED:
PATIENT INFORMATION
Patient’s last name:
First:
Middle:
 Mr.
 Miss
Marital Status:
 Mrs.
 Ms.
Single
Mar
Div Sep Wid
Email: __________________________________________________
Is this your legal name:
If not, what is your legal name?
(Former Name):
Birth Date:
Age:
Sex:
 Yes
 No
 M
F
Mailing address:
Social Security No:
Home phone no: (
)
Work phone no: (
)
Cell phone no:
(
)
Physical Address:
City:
State:
Zip Code:
Occupation:
Employer:
Employer phone no:
(
)
Race: White
Black
American Indian or Alaskan Native
Other
Referred by: Family
Friend
Close to home/work
Asian or Pacific Islander
Yellow Pg
Other
Ethnic Origin Hispanic or Latino
Not of Hispanic or Latino Origin Declined
Military Status: Served in Military Did not serve in Military
Language: English
Spanish
Other
Migrant or Seasonal worker: Yes
No
INSURANCE INFORMATION
(Please give your insurance card to the receptionist)
Is this patient covered by insurance?
Yes
No
Please indicate primary insurance
Subscriber’s name:
Subscriber’s S.S. no.:
Birth Date:
Group no:
ID no:
Co-Payment:
$
Subscriber’s Address:
Home Phone: (
)
Occupation:
Employer:
Employer address:
Employer phone no.:
(
)
Patient’s relationship to subscriber: Self
Spouse
Child
Other
Name of Secondary insurance (if applicable):
Subscribers name:
Group no:
ID no:
Patient’s relationship to subscriber: Self
Spouse
Child
Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at the same address)
Relationship to patient:
Home phone no:
Work phone no:
(
)
(
)
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly
to the physician. I understand that I am financially responsible for any balance. I also authorize E. A. Hawse
Health Center or insurance company to release any information required to process my claims. I authorize E. A.
Hawse Health Center to perform any necessary treatments of diagnostic tests for Medical or Dental services.
____________________________________________________________
_________________
Patient/Guardian Signature
Date
Cd5:\RegistrationFormMedical\blt\6.1.12
Updated 9/10/2015

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form 1 - Gp Medical Registration Form - Gms1 - University Of Sheffield Form 1 - Gp Medical Registration Form - Gms1 - University Of Sheffield Medical
Form 10-7959f-1 - Foreign Medical Program (fmp) Registration Form - Department Of Veterans Affairs Form 10-7959f-1 - Foreign Medical Program (fmp) Registration Form - Department Of Veterans Affairs Legal
Medical Registration Form Medical Registration Form Medical
Medical Office Registration Form - Palola Dental Medical Office Registration Form - Palola Dental Medical
Medical Registration Form Medical Registration Form Medical
Registration And Medical Release Form Registration And Medical Release Form Legal
Medical Registration Form Medical Registration Form Life
County Of Mendocino Medical Cannabis Activity Registration Form County Of Mendocino Medical Cannabis Activity Registration Form Medical
New Patient Registration Form - Westwood Medical Centre New Patient Registration Form - Westwood Medical Centre Medical
Buffalo Medical Group Patient Registration Form Buffalo Medical Group Patient Registration Form Medical

Related Categories

Parent category: Life
Download
Go