New Patient Information Alyeska Family Medicine
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1REGISTRATION FORM
PATIENT INFORMATION
(Please Print)
Prefix
Suffix
Patient’s last name:
First:
Middle:
Marital status
Sex:
M F
Preferred Name (Nickname):
(Maiden Name):
Birth date:
Social Security no.:
Drivers License no./ State
Mailing Address:
City:
State:
ZIP Code:
Street Address:
City:
State:
ZIP Code:
Home phone no.:
Cell Phone no.:
Employer phone no.:
Preferred Contact Method:
Phone Mail Portal
Dr.
Insurance Plan
How did you hear about us? (please check one box):
Family/Friend
Phone Book
Our Website
Other _____________________
______________________
(Name)
Living Will: Yes No
: Yes No
Advance Directives
(If yes, please provide copy)
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:
Birth date:
Social Security no.:
Sex:
M F
Mailing Address:
City:
State:
ZIP Code:
Relationship to patient: Self Spouse Child Other
Yes
No
Is this patient covered by insurance?
Name of Primary insurance
Subscriber’s Name:
Subscriber’s S.S. no.:
Birth date:
Group no.:
Policy no.:
Patient’s relationship to subscriber: Self Spouse Child Other
Name of secondary insurance
Subscriber’s Name:
Subscriber’s S.S. no.:
Birth date:
Group no.:
Policy no.:
(if applicable):
Patient’s relationship to subscriber: Self Spouse Child Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Work phone no.:
Patient/Guardian signature
Date
PRINT
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Parent category: Medical