Patient Registration Form 2024

Patient Registration Form
Patient Information*

Last NameMiddle InitialFirst Name
Birth Date*

MonthDayYear
Date
Social Security Number
Home Phone
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Summer Address

Street Address

Street Address Line 2

CityState

Zip Code
YesNo, I don't have emailNo, I will not discloseNo, Other
Email Address*

Confirmation Email
Primary language spoken*
Yes
Pharmacy Name
Pharmacy Address
MaleFemaleFemale-to-Male / Transgender Male / Trans ManMale-to-Female / Transgender Female / Trans WomanGenderqueer, neither exclusively male nor femaleChoose not to discloseOther
WhiteBlack or African-AmericanAsianAmerican Indian or AlaskanNative HawaiianOther Pacific IslanderRefuse to Report
Hispanic or LatinoNot Hispanic or LatinUnknown
HandicappedVisually ImpairedHearing ImpairedCognitively Impaired
Choose not to discloseLesbian, gay or homosexualStraight or heterosexualBisexualDo not know Something else, please describe
Emergency Contact (other than patient)

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Who is responsible for this account?*
Name of person(s) responsible for this account*

First NameLast Name
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Date of Birth*

MonthDayYear
Date
Relationship to patient*
Home PhoneCell Phone
I authorize Refuah Health Center to disclose, verbally, in writing or via the patient portal, individually identifiable health information about me, or the patient as listed above, to the following:
Insurance Information
No, I am not insuredYes, I am insured (please provide a copy of your insurance card to Refuah)
Primary Insurance*
If you can’t find your insurance on the drop down list, please enter your insurance name and insurance phone number.
Primary Insurance ID#*
Secondary Insurance
If you can’t find your insurance on the drop down list, please enter your insurance name and insurance phone number.
Secondary Insurance ID#
License ID Number
Upload a picture of your license here:

Cancelof
Upload pictures of the front and back of your insurance card here:

Cancelof
By signing this form, I attest that all of the information above is accurate and true to the best of my knowledge and belief.
Employment/School Information

If both employed and student are applicable, please select student.
Employed Full TimeEmployed Part TimeStudentNot EmployedSelf EmployedRetiredOn Active Military DutyReserved for national assignmentVeteran
Not a Farm WorkerMigrantSeasonal
Employer's Name
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Job Title
School Name
School Phone
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I live in my own apartment/house, which is my permanent residenceI temporarily joined households with someone/another familyI live with different people and move aroundI live in a shelterI live on the streetI live in public housing
TextMobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By checking this box, I agree to receive SMS messages from Refuah Health Center related to customer care, including appointment information, and promoting Refuah educational events, and public service announcements, including Fidelis recertification deadlines. You may reply STOP to opt-out at any time. Reply HELP for assistance. Messages and data rates may apply. Message frequency will vary.By checking thix box, I agree to receive phone and marketing text messages from Refuah Health Center, including via automated dialing technology.
Learn more on our Privacy Policy and SMS Terms and Conditions https://form.jotform.com/250906838691165
Signature

Clear
Date

MonthDayYear
Date
Consent for Testing and Treatment

I give permission to Refuah Health Center to perform such tests, treatments and procedures as ordered by the medical, dental, or behavioral health staff for diagnostic and/or therapeutic purposes, including but not limited to, x-rays and the administration of pharmaceutical products and medication, in addition to the drawing of blood. I acknowledge that no guarantees or assurances have been made to me concerning the results of findings intended from treatment or examination at Refuah Health Center.

I understand and acknowledge that Refuah prohibits all photography and audio/video recording on its premises and agree to refrain from taking any photos/videos/audio recordings while I am on site
Language Assistance

I understand I have the right to language assistance services and appropriate auxiliary aids and services free of charge, when necessary to comply with Section 1557 of the Affordable Care Act.
Authorization
By signing this form, I attest that all of the information above is accurate and true to the best of my knowledge and belief.
Signature of patient or legally authorized representative*

Clear
Date*

MonthDayYear
Should be Empty:

Patient Registration Form

Insurance Information

Employment/School Information

Authorization