ADULT REGISTRATION
WESTERN WAKE WELLNESS, PLLC
PATIENT INFORMATION
Today's Date:
*
-
Month
-
Day
Year
Legal Name
*
First Name
Last Name
Nickname:
Date of birth:
*
-
Month
-
Day
Year
Age:
*
Patient's Email Address:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Language
English
Other
The best way to contact me is:
Phone
Email/Patient Portal
Postmail mail
Sex at birth:
Male
Female
Gender:
Male
Female
Nonbinary
Transman
Transwoman
Other
My pronouns are:
She/hers
He/his
They/their
I Identify as:
Straight, Heterosexual
Gay, Lesbian, Homosexual
Bisexual
Something Else
Don't know
Marital Status:
Single
Married
Domestic Partnership
Divorced
Widowed
Do you think of yourself as:
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
I prefer not to answer
Other
My ethnicity is:
Hispanic or Latino
Not Hispanic or Latino
I prefer not to answer
GUARANTOR INFORMATION
Person responsible for bill. Please use full legal name
Relationship to Patient:
*
Self
Spouse
Parent
Child
Other
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
Home Phone:
*
Format: (000) 000-0000.
Social Security Number:
Employer Name & Address:
PRIMARY HEALTH INSURANCE
(Please bring your card with you to every appointment)
Insurance Company:
Policy Holder Name:
Relationship to Patient:
Member ID #
Group ID #
Effective Date:
-
Month
-
Day
Year
Employer Name & Address:
SECONDARY INSURANCE
Insurance Company:
Policy ID #
Member ID #
Group #
Effective Date:
-
Month
-
Day
Year
EMERGENCY CONTACT
Name
*
Relationship
*
Phone number
Format: (000) 000-0000.
Which Pharmacy do you prefer to use for prescriptions:
Name / Address
Who may we thank for referring you to our practice?
Submit
Should be Empty: