Patient Registration Form (Columbus)

Chart Number _______________
Patient Registration (Columbus)

Note: Each patient must complete a separate form.
Name *

First Name Last Name
SSN# *
Personal Pronouns
Date of Birth *
Ethnicity *
Race *
Language *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Source of Referral:

We are happy you have chosen Centerstone Health Services for your healthcare needs. How did you hear about us?
Facebook Ad Friend or Family Member Billboard Advertisement Newspaper Ad
Photo ID

Please upload a photo of the front and back of your driver's license or state issued ID card (jpg or png).
Upload a Photo of Your Driver's License or State Issued ID

Browse Files

Cancel of
Insurance Card

Please upload a photo of the front and back of insurance card (jpg or png).
Browse Files

Cancel of
Messaging
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
May we leave messages or text appointment reminders to the mobile number above? *

Yes No
Do you prefer text reminders or a phone call *

Text Phone Call
Email
Email *
example@example.com
Would you like to sign up for our eNews? *

Yes No
Homelessness
Homeless Status (if applicable)

Homeless Shelter Transitional Housing Doubling Up Street Other Unknown
Zipcode of Shelter (if applicable)
Marital Status
What is your marital status? *

Single Married Separated Divorced Widow(er)
Military Status
Military or Veteran *

Yes No
Education
Last grade of school completed *
College Degree *

Yes No
Employment
Employer Name (first job) *
Annual income *
Employer Name (2nd job)
Annual Income
Insurance & Billing Information
Subscriber's Name *

First Name Last Name
Subscriber's Date of Birth *
Insurance Name *
Policy ID *
Group # *
Medicaid Number
Medicare Number
Medicare Plan

A B D
Self Pay *

Yes No
Party Responsible for Payment

If the responsible party is the patient, the patient may leave this section blank.
Name

First Name Last Name
Date of Birth
SSN#
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Phone Number for Messages

Area Code Phone Number
Employer
Income
Other Income
Agreement

I give Centerstone Health Services permission to provide care and treatment.
Signature *

Clear
Date *

Month Day Year
Date
Please verify that you are human *
Should be Empty:

Patient Registration (Columbus)

Source of Referral:

We are happy you have chosen Centerstone Health Services for your healthcare needs. How did you hear about us?

Photo ID

Insurance Card

Messaging

Email

Homelessness

Marital Status

Military Status

Education

Employment

Insurance & Billing Information

Party Responsible for Payment

Agreement