Patient Registration Form - Premier Medical Associates

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PATIENT REGISTRATION
Welcome to our office. Please provide us with the following information. If you have any questions or
concerns, please contact a staff member. Thank you kindly. PLEASE PRINT.
Building Better Care
Last Name _________________________________________ First Name _______________________________________ MI _____
SS# ______-____-________ Date of Birth ____/____/________
Sex
Male
Female
Address ______________________________________________________________________________________ Apt/Suite ______
Zip Code __________ City ______________________________________________________ State ____
Main Contact Phone Number (______)______-________ Is this the
Home
Cell
Work
Other Contact Phone Number (______)______-________ Is this the
Home
Cell
Work
If a parent or guardian, please indicate relationship ___________________________________________
Other Contact Phone Number (______)______-________ Is this the
Home
Cell
Work
If a parent or guardian, please indicate relationship ___________________________________________
Employer ____________________________________________________________________
Address ______________________________________________________________________________________ Apt/Suite ______
Zip Code __________ City ______________________________________________________ State ____
Email Address ________________________________________________________________
Marital Status
Single
Married
Divorced
Widowed
Seperated
Employment Status
Full Time
Part Time
Not Employed
Self Employed
Retired
Military Duty
Student Status
Full Time
Part Time
Not A Student
The following information is mandated by the Federal government as part of healthcare reform. Please note that this information is not
used by Premier Medical Associates in any way.
Race
Asian
Native Hawaiian or Pacific Islander
Hispanic
Black or African American
White
Declined
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Declined
Preferred Language
English
Other ____________________________________________________________________
This section designates who will be responsible for payment of the account. Unless a minor or an adult with a special circumstance, the
patient is the responsible party. This section does not reflect the subscriber of any insurance policies.
Person Responsible for the Account is
Patient
Parent/Guardian
Other ________________________________________
(if the patient is not financially responsible, please complete the following)
Last Name _________________________________________ First Name _______________________________________ MI _____
SS# ______-____-________ Date of Birth ____/____/________
Sex
Male
Female
Address ______________________________________________________________________________________ Apt/Suite ______
Zip Code __________ City ______________________________________________________ State ____
Main Contact Phone Number (______)______-________ Is this the
Home
Cell
Work
Emergency Contact Information
Last Name _________________________________________ First Name _______________________________________ MI _____
Main Contact Phone Number (______)______-________ Is this the
Home
Cell
Work
Other Contact Phone Number (______)______-________ Is this the
Home
Cell
Work
Relationship
Spouse
Parent/Guardian
Child
Sibling
Other ______________________________________________

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