Patient Registration Form

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Patient Registration
PERSONAL INFORMATION
Patient Name: (Last) _____________________________________(First)_________________________(Middle)_______
Birth date: ____________
Sex: M or F
Marital Status: S
M
D
W
:
Language
__________________________
Race:
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian /Other Pacific Islander
White
Choose not to answer
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Choose not to answer
Address: (Street)____________________________________________(City/State)_______________________(Zip)________
Preferred Phone:_____________________ Type: Cell or Home or Business
Preferred Method of Contact: Phone or US Mail
E-mail: _____________________________________________
Employment Status: _______________________________
Guarantor Name:_____________________________________ Relationship to Guarantor: ______________________________
Guarantor Address: (Street) ______________________________________ (City/State) _____________ (Zip) _____________
Emergency Contact: __________________________________ Phone:_____________ Relationship:______________________
AKA/Nickname: _____________________________________ Patient Needs: ______________________________________
Referring Physician: _________________________________ Address: ____________________________________________
INSURANCE INFORMATION
Primary Insurance Co. Information: (name, address and phone # of person responsible for payment)
Insurance Company Name: _____________________________________________Phone: ___________________________
Policy/ID Number: ____________________________Group #: __________________ Effective Date: __________________
Subscriber’s Name: _____________________________________ Relationship to Patient____________________________
Subscriber’s DOB: _______________
Subscriber’s Sex: _____________
Address: __________________________________________________________________ Phone: ____________________
Subscriber’s Employer: _________________________________________________________________________________
Secondary Insurance Co. Information: (name, address and phone # of person responsible for payment)
Insurance Company Name: ______________________________________________ Phone: ___________________________
Policy/ID Number: _____________________________ Group #: ________________ Effective Date: ____________________
Subscriber’s Name: _______________________________________ Relationship to Patient__________________________
Subscriber’s DOB: ____________________
Subscriber’s Sex: _____________
Address: ___________________________________________________________Phone: ___________________________
Subscriber’s Employer: ________________________________________________________________________________
Signature: _______________________________________________________________ Date: ______________________
For Internal Use Only:
Scan document into Registration Forms Faceheets folder in CB
Revised 5/14

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Parent category: Medical
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