New Patient Enrollment Form

Patient Registration Form

Eastbay Medical Clinics
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
Preferred language:
Cell Phone Number:
Format: (000) 000-0000.
We will text you appointment reminder
Second Contact Number:
Format: (000) 000-0000.
E-mail
example@example.com
We will email you appointment reminder and other email:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency
Emergency Contact:

First NameLast Name
Relationship
Contact Number
Format: (000) 000-0000.
Who we can share your file and information with:
Confidential Contact:

First NameLast Name
Contact Number
Format: (000) 000-0000.
What is your primary insurance?
Name of insurance
Name of individual insured:
Insured under:
Take picture of the front of your primary insurance card:
Take picture of the back of your primary insurance card:
Do you have secondary insurance? (if you do not provide us with correct information it will have financial implications for you)
Name of insurance
Name of individual insured:
Insured under:
Take picture of the front of your secondary insurance card:
Take picture of the back of your secondary insurance card:
Take picture of the front of your government ID card: In case you do not have it now, you MUST bring the ID during your first appointment otherwise you can not be seen.
Signature
Today's Date:
Should be Empty:

Patient Registration Form