Amarillo Medical Specialists Endocrinology Registration

Patient Registration Form

Please fill in the form below. All information is encrypted in secure format.
Date*
Doctor Requested*

Dr. Cristina Caga-ananDr. William BiggsNext Available DoctorDr Susan Wingo (diabetes only)
Best Day of Week for your appointment

No preferenceMondayTuesdayWednesdayThursdayFriday morning
Full Legal Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Gender:

FemaleMaleOther
Marital Status

SingleMarriedDivorcedWidowedSeparatedOther
We are required to ask for Race and Ethnicity. Please select all that apply.

Native American or AlaskanAsianBlack or African AmericanWhiteHispanicDecline to stateOther
Is patient the person responsible for bill?

YesNo, a person at same addressNo, someone else
Patient Social Security Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Home Number*
Work Number
Occupation:
Employer
Who is your primary care doctor?
We customarily share our findings with your PCP
Any Special Needs

NoYes
Please tell us your special needs.
Financially Responsible Person Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Responsible Person Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Insurance (Primary)

Insurance Company Name

Insured's Name (as on file with Insurance Company)

Relationship to InsuredSubscriber Number

Group Number
Do you have secondary insurance?

YesNo
Medical Insurance (Secondary - if applicable)

Insurance Company Name

Insured's Name (as on file with Insurance Company)

Relationship to InsuredSubscriber Number

Group Number
E-mail*
May we have your best Emergency Contact*

YesNo
Is this person also able to recieve HIPAA confidential information?*

YesNo
Emergency Contact Contacts Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Emergency Contact Person Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Cell Number
Emergency Contact Home Number
Your Preferred Local Pharmacy
Include address so we can route your prescriptions to the best place for you.
Your Preferred Mail Order Pharmacy
Include address so we can route your prescriptions to the best place for you.
Signature*

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How did you hear about us?*

AdvertisementGoogle or Intenet SearchPersonal RecommendationReferral by Family DoctorReferral by Insurance CompanyOthers
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Amarillo Medical Physicians and the physician. I understand that I am financially responsible for any balance not covered by insurance. I also authorize Amarillo Medical Specialists, LLP, my physician, or insurance company to release any information required to process my claims.
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Patient Registration Form