Medical Registration Form

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Date:
Date of Birth: ________________________
_____________________
Social Security #:_____________________
Patient Full Name: _____________________________________________________________________________
Address: _____________________________________________________________________________________
City: _____________________________________ State: __________________ Zip: ______________________
Contact numbers: Home__________________ Cell Phone: ___________________ Relative: _________________
Best time to reach you: ________ day ________ Night
Email address: _______________________________
Gender: Male________ Female________ Age: _______________
( ) Married ( ) Widowed ( ) Single ( ) Separated ( ) Divorced ( ) Life Partner
Student Status: Fulltime ____ Part-time _____ Not a student ____ Veteran Status: Yes____ No____
Smoker: Yes____ No____
Emergency Contact Name: ____________________________________ Contact number: __________________
****************We are required to obtain the following requested information********************
Homeless status: Not homeless____ Doubling up____ Shelter___ Street ____ Transitional___
Migrant worker: Migrant ______ Not a farm worker ______ Seasonal ______
Language Barrier: Yes ____ No ___ What is your primary Language Spoken:_________________________
Race: Native American Indian ____ Native Hawaiian ____ White ____ Asian ____ Black/African American ____
Other Pacific Islander ____ Hispanic ___
Ethnicity: Hispanic/Latino ____ Not Hispanic ____
Primary Care Provider: ______________________________ Primary Dentist: __________________________
Primary Insurance Coverage: ____________________________________________________________________
Subscribers Name: ______________________________ Relationship to Patient: __________________________
Additional Insurance Coverage: __________________________________________________________________
Number of family members in household: __________________________________________________________
How did you hear about CHDC? __________________________________________________
*****State your household income in one of the following categories listed below******
Household income: Weekly _________ Biweekly________ Monthly _________ Yearly________
Financial Responsibility
All professional services rendered are charged to the patient and are due at the time of service, unless other
arrangements have been made in advance with our Patient Financial Department. Although we will compile the
necessary forms to file to your insurance company it is the responsibility of the patient to dispute any services not
covered by the insurance company.
I further understand that fees are due and payable on the date services are rendered and agree to pay all such charges
incurred in full immediately upon presentation of the appropriate statement.
___________________________________________________________
___________________________________________________________________
Patient Signature
Date
Signature of guardian if patient is under 18 years
Date
S:/Patient Services 2012/Front Office

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