Patient Registration Form
Patient Information
Patient Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Marital Status
*
Single
Married
Divorced
Widowed
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone:
Please enter a valid phone number.
Preferred Phone is a:
Home
Work
Cell
Email
example@example.com
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Decline to Answer
Race
American Indian/Alaskan Native
Asian
African American
Native Hawaiian/Pacific Islander
White
Other
Decline to Answer
Guarantor if not the patient
Financially responsible party for minor or incapacitated adult
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Relationship to the Patient:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone:
Please enter a valid phone number.
Preferred Phone is a:
Home
Work
Cell
Email:
example@example.com
Emergency Contact
Emergency Contact Name:
*
First Name
Last Name
Relationship to the Patient:
*
Phone Number:
*
Please enter a valid phone number.
Insurance Information
Are you currently insured? (If YES, complete the insurance fields below)
*
Yes - I have insurance
No - I DO NOT have insurance
Primary Insurance Carrier:
ID Number:
Group/Plan Number:
Copay:
Subscriber:
Subscriber DOB:
-
Month
-
Day
Year
Date
Subscriber Phone:
Please enter a valid phone number.
Subscriber Address (if different from the client's):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber Email:
example@example.com
Subscriber Employer:
Secondary Insurance Carrier:
Secondary ID Number:
Secondary Group/Plan Number:
Secondary Copay:
Secondary Subscriber:
Secondary Subscriber DOB:
-
Month
-
Day
Year
Date
Secondary Subscriber Employer
Signature
*
Printed Name:
*
Relationship to Patient:
Date:
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: