Lubbock ER Registration Form

Lubbock - Patient Registration Form
Please Note:

This form will take approximately 10 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature.

You will also be asked to take a picture of your license and insurance card.

All information is Confidential.

Section 1

Patient Information
Patient's Full name *

First Name Last Name
ErxConfirmationNumber
Social Security Number *
Email Address *
Phone Number *
Date of Birth *

Month Day Year
Date
Sex *

Female Male
Marital Status *

Single Married Divorced Separated Widowed Other
Date

Month Day Year
Date
Age
Address *

Street Address

Apartment/Suite Number

City State

Zip Code Country

Employment Information
Employer Name
Employer Phone Number
Occupation
Preferred Method of Contact

Phone Work Email Other
Preferred Method of Contact

Section 2

Identification Information
Upload the Front of Your Driver's License

Cancel of
Upload the Back of Your Driver's License

Cancel of

Section 3

Insurance Information
Upload the Front of Your Insurance Card OR Fill Out Manually on the Next Pages

Cancel of
Upload the Back of Your Insurance Card OR Fill Out Manually on the Next Pages

Cancel of

Do you have secondary insurance?

Yes No

Section 6

Race/Ethnicity
Race *

American Indian/Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White
Ethnicity *

Hispanic or Latino Not Hispanic or Latino