Capital Health Group Patient Registration Form

Patient Registration Form
Therapist
Patient Demographic Information
Patient Name
Social Security #
Street Address
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
City, State, Zip Code
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Gender
Email Address
example@example.com
Mobile Phone
Format: (000) 000-0000.
Primary Physician:
Format: (000) 000-0000.
Psychiatrist (if any)
Emergency Contact Person:
Format: (000) 000-0000.
Emergency Contact Phone
Format: (000) 000-0000.
How did you hear about us?
Marital Status
Responsible Party is the person who will be paying the per-session fee for services (leave blank if same as patient)
Responsible Party
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Street Address
City, State, Zip Code
Relationship to Patient
Responsible Party SSN
Insurance Information
Primary Insurance
Please upload a picture of the FRONT of your insurance card

Cancelof
Please upload a picture of the BACK of your insurance card

Cancelof
Policy Holder Name
Company Address
Policy Holder Date of Birth
City, State, Zip Code
Identification Number
Company Phone
Policy/Group Number
Employer
Policy Holder SSN
Secondary Insurance
Policy Holder Name
Company Address
Policy Holder Date of Birth
City, State, Zip Code
Identification Number
Company Phone
Policy/Group Number
Employer
Policy Holder SSN
By signing, I willingly choose Capital Health Group, LLC to be my service provider. My signature below confirms that I have selected my service provider freely, without influence, pressure, or coercion.
Parent or Guardian (if applicable)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: