Patient Registration Form - 18 Years Of Age Or Older (No Dependants)
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1
2Pediatric Associates of Western CT
2016
Patient Registration – 18 Years of Age or Older (No Dependants)
Primary Care Provider (PCP) - __________________________________________________________
Patient Name: Last Name: ____________________________ First Name: ___________________________ MI: _____
D.O.B.: _____/_____/_____ Sex: _______ Primary Language: __________________
Ethnicity: Hispanic / Non-Hispanic / Unknown
Race: Asian / Black / Hawaiian / White
Mailing Address: ____________________________________________________________________________
(Street or PO Box)
(City)
(State & Zip)
○Home Phone: ( ____ ) _____ - ______ ○Cell Phone: ( _____ ) _____ - ______
Please check preferred number to call(○)
Email: ______________________________________ Necessary for patient portal (please write legibly)
Employer: _________________________________ Occupation: ________________________________
How would you ideally prefer to be contacted regarding (circle one):
Medical Issues: Home Phone / Work Phone / Cell Phone / Home Email
Appointment Reminders: Home Phone / Cell Phone / Home Email
Recall Notices: Home Address / Home Phone / Work Phone / Cell Phone / Home Email
Billing Statements: Home Address / Home email
General Practice Notices: Home Address / Home Phone / Cell Phone / Home Email
Patient Portal Notifications: Cell Phone / Home Email
Do you live with your parents?
Yes
No
Parent 1: Name: ___________________________________ Relation to Patient: ________________________________
Date of Birth: ____ / ____ / ____
Social Security #: ______ - _____ - _______
Work Phone: ( ____ ) ______ - ___________ Cell Phone: ( ____ ) ______ - ___________
Address: _______________________________________________________________________________________
(Street or PO Box)
(City)
(State & Zip)
Parent 2: Name: ____________________________________ Relation to Patient: _____________________________
Date of Birth: ____ / ____ / ____
Social Security #: ______ - _____ - _______
Work Phone: ( ____ ) ______ - ___________
Cell Phone: ( ____ ) ______ - ___________
Same address as Parent #1 (Circle One)
Yes / No
If not write other address _____________________________________________________________________________
Insurance:
Primary Policy: Policy Holder’s Name: _________________________________________________________
Policy Holder’s Birth Date: _____________________ Policy Holder’s Sex: Male / Female
Insurance Carrier: __________________________________________
ID# ______________________________________ Group # __________________________
Secondary Policy: Policy Holder’s Name: _______________________________________________________
Policy Holder’s Birth Date: ___________________ Policy Holder’s SSN: _____________
Insurance Carrier: __________________________________________
ID# ______________________________________ Group # __________________________
Review additional information on reverse side
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