New Patient Registration

New Patient Registration

The Purcell Clinic
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Patient Race*
Patient Ethnicity*
Parent/Guardian*

First NameLast Name
Relationship to Patient*
Parent/Guardian Date of Birth*

MonthDayYear
Date
Email
example@example.com
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Can we leave a detailed message regarding medical care and lab results on these numbers?

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the patient reside at the above address?

YesNo
Additional Parent/Guardian Name

First NameLast Name
Additional Parent/Guardian Phone Number
Please enter a valid phone number.
Does the additional Parent/Guardian listed above have permission to bring patient to appointments and make medical decisions?

YesNo
Patient Insurance Information

All information must be completed fully in order for patient to be scheduled.
Patient Primary Insurance *

Insurance Company/NameSubscriber Number
Primary Insurance- Policy Holder Information

Policy Holder First & Last Name

Policy Holder Date of Birth

Policy Holder Social Security Number

Patient Relationship to Policy Holder
Secondary Insurance

Insurance Company/NameSubscriber Number
Secondary Insurance- Policy Holder Information

Policy Holder First & Last Name

Policy Holder Date of Birth

Policy Holder Social Security Number

Patient Relationship to Policy Holder
By providing my electronic signature below, I hereby authorize and give consent to The Purcell Clinic providers and other practice professionals providing outpatient medical treatment, supplies, drawing blood, or any other procedure related to my healthcare or to my child/dependent as determined necessary in their professional judgement.

I understand that I am financially responsibile for all charges paid or unpaid by my insurance company. I hereby authorize the release of information necessary to file a claim with my insurance company and assign payment of all medical benefits to The Purcell Clinic. I also authorize the release of my childs/dependents medical information by or between any of my treating physicians and my insurer or any other entity included in the administration of my child's/dependent's health benefits.

All information provided is truthful and accurate to my knowledge. This consent is in place until termination in writing by the undersigned.
Signature*

Clear
Signature Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

New Patient Registration

Patient Insurance Information