Patient Registration Form Patient Information
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325 Northridge Lane
Lexington, VA 24450
Phone: 540-464-8700
Fax: 540-464-1323
PATIENT REGISTRATION FORM
Patient Information
Last Name
First Name
Middle Initial
Mailing Address
City
State
Zip Code
Physical Address (if different than mailing)
Home Phone
Cell Phone
Work Phone
Date of Birth
Gender
Marital Status
❒ M ❒ F ❒ Transgender
❒ Single ❒ Married ❒ Divorced ❒ Widowed
Social Security Number
Email address
How did you hear about RAHC?
Over half of RAHC’s Board of Directors are current patients.
Would you be interested in hearing more about becoming a
board member?
❒ Yes
❒ No
Financial Responsibility
❒ Self ❒ Parent ❒ Legal Custodian ❒ Guardian/Power of Attorney
Last Name
First Name
Address
❒ Same as above
City
State
Zip Code
Date of Birth
Social Security Number
Home Phone
Employment Information
Are you employed?
Name of Employer
❒ Full-time ❒ Part-time ❒ Retired ❒ Not Employed
Employer Address
City
State
Zip Code
Are you a student?
Are you active duty military?
❒ Full-time ❒ Part-time ❒ Not a Student
❒ Yes
❒ No
Emergency Contact #1
Last Name
First Name
Mailing Address
City
State
Zip Code
Home Phone
Cell Phone
Relationship to Patient
Emergency Contact #2
Last Name
First Name
Mailing Address
City
State❒
Zip Code
Home Phone
Cell Phone
Relationship to Patient
04252016 Reg
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Parent category: Medical