PATIENT REGISTRATION
711 W. 38th St. F-2, Austin, TX 78705 | Phone: (512) 637-5841 | Fax: (512) 637-5997
PATIENT INFORMATION
(If your child is the patient, please provide their information here)
Name
*
First Name & Middle Initial
Last Name
Date of Birth
*
/
Month
/
Day
Year
Preferred Name
What sex is listed on your birth certificate?
*
Male
Female
Prefer not to say
Marital Status
Single
Married
Divorced
Widowed
What is your gender identity?
Please Select
Male
Female
Other (please specify below)
Prefer not to say
Specify gender identity
Please Select
Transgender man/trans man/female-to-male (FTM)
Transgender woman/trans woman/male-to-female (MTF)
Genderqueer/gender non-conforming
Other (please describe below)
Prefer not to say
Gender identity
What pronouns do you prefer that we use when talking about you?
He/him/his
She/her/hers
They/them/theirs
Other (please specify below)
Preferred pronouns
Email Address
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Mobile phone
*
Home phone
Work phone
Occupation
Employer or Name of School
Employer Address
Street Address
Street Address Line 2
City
State
Zip Code
Please upload a picture of your drivers license or state issued ID (Guardians ID if the patient is a minor or does not have an ID).
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FINANCIALLY RESPONSIBLE PARTY INFORMATION
Is the patient the financially responsible party?
*
Yes
No
Name of financially responsible party
First Name & Middle Initial
Last Name
Relationship to Patient
Email Address
Home Address
Street Address
Street Address Line 2
City
State
Zip Code
Mobile phone
Occupation
Employer or Name of School
Employer Address
Street Address
Street Address Line 2
City
State
Zip Code
Spouse (or Parent Not Listed Above):
First Name
Last Name
Relationship to Patient
Email Address
Home Address
Street Address
Street Address Line 2
City
State
Zip Code
Home phone
Mobile phone
REFERRAL INFORMATION
Referred by
Phone #
Address
Street Address
Street Address Line 2
City
State
Zip Code
Primary Care Physician
Phone #
If you are seeing Dr. Allen and using insurance, please upload a picture of the FRONT AND BACK of your insurance card.
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ALTERNATE EMERGENCY CONTACT
Name of person not living with you
First Name
Last Name
Primary phone
Submit
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