New Patient Registration Form

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New Patient Registration Form
Copay $ ________
General Information (please print)
Name: ___________________________________________ DOB ____________________
Sex: __M __F
Social sec # ____________________________ Marital status: Single___ Married___ Divorced ___Widowed ___
Primary address ____________________________________________________________________________
City __________________________________________ State _______________ Zip ____________________
Home phone _____________________Work phone ____________________ Cell phone ___________________
Emergency contact _______________________ Relationship __________________ Phone ________________
E-mail ___________________________________________________________ Authorize E-mail? ___Y ___N
Pharmacy name ________________________________ Phone _________________ Fax _________________
Employment status:
___employed
___not employed
___retired
___student
Employer: ________________________________________ Occupation _______________________________
Patient Phone Message Consent
It is our policy to notify you of test results ordered by this office and to call you to confirm appointments. This is to acknowledge
that you authorize us to:
Leave a detailed message on voice mail/machine/cell
YES _________ NO ________ (initial yes or no)
•
Leave a detailed message with individual answering the phone
YES _________ NO ________ (initial yes or no)
•
Sharing of Medical Information
I give the physician and office staff of UDFMC permission to discuss my medical condition with the following individuals:
Name:________________________________________________________
Relationship:________________________
Name:________________________________________________________
Relationship:________________________
Name:________________________________________________________
Relationship:________________________
Doctor Information
Referring Physician ________________________________________
Specialty ________________________
Primary Care Physician _____________________________________
Phone __________________________
Primary Insurance
Insurance name _____________________________________ Subscriber’s name ________________________
Insurance ID#: _______________________________________________________________________________
Social Sec # _________________________ DOB ______________ Relationship to insured _________________
Secondary Insurance
Insurance name _____________________________________ Subscriber’s name ________________________
Insurance ID#: _______________________________________________________________________________
Social Sec # _________________________ DOB ______________ Relationship to insured _________________
 

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