PATIENT REGISTRATION
Please fax to 916.784.7548 or mail to us prior to your appointment
Name ________________________________________________________________________________________
Last
First
MI
Address ______________________________________________________________________________________
Street
City
State
Zip
Telephone (____)_____________________(____)_______________________(____)_________________ext_____
Home
Cell
Work
Primary care physician _______________________
Marital Status
!S
!M
!D
!W
Referred by __________________________________
SSN _________________________________________
Date of Birth _________________________________
Emergency Contact __________________________
Last Name
First Name
Gender
! Male
! Female
______________________________________________
Phone Number
Relation (spouse, parent, etc)
INSURANCE INFORMATION
Please present your insurance card to the receptionist
! Self Pay (no insurance)
Primary Insurance Co __________________________
Secondary Insurance Co ________________________
Relation to policyholder __________________________
Relation to policyholder __________________________
(self, spouse, child, etc)
(self, spouse, child, etc)
If patient is NOT the policyholder, please fill out the
If patient is NOT the policyholder, please fill out the
following: ______________________________________
following: ______________________________________
Policyholder’s Last Name
First Name
DOB
Policyholder’s Last Name
First Name
DOB
Email _______________________________________________________
Race
!Decline to report
!American Indian or Alaska Native
!Asian
!Native Hawaiian or Other Pacific
!Black or African American
!Other Race
______________________
!White
!Hispanic
TELEPHONE INFORMATION and COMMUNICATION RELEASE
May we leave medical information on your home answer machine?
! Yes ! No
May we leave medical information on your cell voicemail?
! Yes ! No
May we discuss your medical information with family members?
! Yes ! No
If yes, please list: ______________________________________________________
REFERRAL INFORMATION
! Physician ________________
! Internet
! Other ____________________
! Family/Friend _____________
! Phone books
(Yellow pages)
Signature _______________________________________________________Date_________________________
1412 Blue Oaks Blvd | Roseville, CA 95747 | 916.784.7546 | Fax 916.784.7548 |