Language
English (US)
Spanish (Latin America)
Patient Registration Form
Name
*
First Name
Middle Name
Last Name
Legal Name (if different from above)
Legal First Name
Legal Middle Name
Legal Last Name
Sex Listed on Insurance
Female
Male
Intersex
Gender Identity
Female
Male
Nonbinary
Other
Pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Prefer not to answer
Other
Sexual Orientation
Lesbian
Gay
Bisexual
Pansexual
Straight (Heterosexual)
Asexual
Other
Date of Birth:
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Can we leave a message here?
Please Select
Yes
No
How did you hear about us?
Email
example@example.com
Would you like access to our Patient Portal?
Please Select
Yes
No
Reason for visit?
Is this a work injury?
Date of last physical:
Is this a 'Welcome to Medicare' visit?
Race:
*
Black or African American
American Indian or Alaska Native
White
Native Hawaiian
Asian
White Hispanic/Latinx
Pacific Islander
Decline
Other
Ethnic group:
*
Hispanic or Latinx
Non Hispanic or Latinx
Other
Martial status:
Married
Divorced
Seperated
Widowed
Single
Emergency Contact
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
Insurance company name:
Please bring insurance card with you for us to copy
ID #
Group #
Subscriber/Guarantor:
Subscriber/Guarantor Date of Birth:
-
Month
-
Day
Year
Date
Relationship to patient:
Employer of subscriber:
Secondary insurance company name:
ID #
Group #
Subscriber/Gaurantor:
Subscriber/Gaurantor Date of Birth:
-
Month
-
Day
Year
Date
Relationship to patient:
Employer of subscriber:
Back
Next
Allergies:
Drug Allergies:
Past Illnesses:
Date
-
Month
-
Day
Year
Date
Past Illnesses:
Date
-
Month
-
Day
Year
Date
Past Surgeries:
Date
-
Month
-
Day
Year
Date
Past Surgeries:
Date
-
Month
-
Day
Year
Date
Medication/Start Date/Dosage
Financial Responsibility: All copays must be paid at the time of service. All deductibles and co-insurance are patient responsibility. All statements for account balances are due upon receipt. Any out of network or Insurance checks sent directly to you for payment must be endorsed and mailed to CIRCLE CARE Center with all supporting documents. If your account is overdue 90 days, you agree to pay all reasonable fees incurred by CIRCLE CARE Center in attempting to collect any debt. No-Shows(failing to show up for your appointment, or cancelling less than 24 hours before your appointment) are subject to a $25.00 fee.
Patient Name (Print)
First Name
Last Name
Patient Signature
Today's date
-
Month
-
Day
Year
Date
Legal Guardian Name (Patients under 18)
First Name
Last Name
Legal Guardian Signature
Today's date
-
Month
-
Day
Year
Date
Print
Submit
Should be Empty: