Registration Form - Convoy Office

Patient Registration

Nicodemus M. Watts, MD, DFAACP
Name *

First Name Last Name
Date *

Month Day Year
Date
Responsible Party's Name
Note "Self" if applicable
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Responsible Party's Social Security # (SSN)
Relationship to Patient
Patient Information
Date of Birth

Month Day Year
Date
Sex
SSN
Primary Care Physician
Physician's Phone:
Physician's Address (if known):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Person (if not Responsible Party)
Preferred Phone:
Relationship to Patient
AUTHORIZATION FOR TREATMENT & TERMS:

I hereby request and consent to evaluation and treatment of the above named as mutually agreed upon between me and physician. Service offered are voluntary and will be conducted in accordance with community standards of care. Services provided will be considered confidential unless release of information is requested by me for designated purposes in the best interest of the patient. I accept responsibility for payment of charges as discussed with the physician. Payment is due at the time of service delivery.

Patient Registration