[Name of Practice]

REGISTRATION FORM

Today’s Date: [Date] PCP: [PCP] PATIENT INFORMATION Patient’s last name: [Last Name] First: [First Name] Middle: [Initial] [Choose an item] Marital status: [Choose an item] Is this your legal name? If not, what is your legal name? Former name: Birth date: Age: Sex: [Legal Name] [Former Name] [Birthday] [Age] Address: [Address/ P.O Box, City, ST ZIP Code] Social Security no.: Home phone no.: Cell phone no.: [SS#] [Phone] [Phone] Occupation: Employer: Employer phone no.: [Occupation] [Employer] [Phone] Chose clinic because/referred to clinic by (Please choose one option): [Doctor’s name] [Choose an item] Other family members seen here: [Other patients] INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: [Responsible party] [Birthday] [Address] [Phone] Is this person a patient here? Is this patient covered by insurance? Occupation: Employer: Employer address: Employer phone no.: [Occupation] [Employer] [Address] [Phone] Please indicate primary insurance: [Choose an item] | Other: [Other insurance] Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: [Name] [SS#] [Birthday] [Group #] [Policy #] $[Co-pay] Patient’s relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber] Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.: [Secondary Insurance] [Name] [Group #] [Policy #] Patient’s relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber] IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: [Friend or relative name] [Relationship] [Phone] [Phone] The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims. Patient/Guardian signature Date