New Patient Registration

New Patient Registration
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone *
Email Address *
Emergency Contact Phone #
Emergency Contact Name
Relationship to the patient
Patients Gender
Date of Birth *
MM/DD/YYYY
Employed

Employed Unemployed Disabled Retired Student
Current Employer
Current University/College
Single

Single Married Divorced Widowed
Preferred Method of Contact
Preferred Pharmacy
Preferred Pharmacy Phone
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How were you referred to our practice?
Insurance Information
Primary Insurance Company Name
Policy Number
Subscribers Name
Date of Birth
MM/DD/YYYY
Subscriber's Relationship to Patient
May we EMAIL via secure portal or leave voice messages regarding TEST RESULTS? *

Yes No
DISCLOSURE OF YOUR HEALTH INFORMATION. Would you like anyone besides yourself to receive information about your appointments, treatment, diagnostic results and/or information pertinent to your healthcare? *

No, I do not authorize my health information to be disclosed to any other parties EXCEPT TO ME THE PATIENT. Yes, I authorize the person(s) listed below to receive ALL HEALTH INFO about appts, treatment and/orinformation pertinent to my healthcare and/or payment for my healthcare.
PATIENT’S CONSENT FOR TREATMENT: I hereby voluntarily request and authorize Hayley Nguyen, MD to examine and treat me. I authorize Hayley Nguyen, MD to release any information acquired during my examination or treatment to my insurance carrier for the purpose of medical claims payment. I authorize payment of medical benefits to Hayley Nguyen, MD. I understand that verification of benefits and filing of a claim does NOT guarantee payment. If my claim is denied, not covered, or remains unpaid by my insurance, I will be responsible for the balance due. *

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