Infusion Center New Patient Form
Please fill out your form as completely and accurately as possible. Information collected on this form will only be used by TriState Health to register for your appointment unless stated otherwise and approved with your clear written consent.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Sex
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Phone Type
*
Please Select
Home
Cell
Work
Other
Email
example@example.com
Infusion Therapy Questions
What medications are you receiving?
*
What hospital or clinic are you currently receiving your medications?
*
Prescribing Physician Information
Physician Name
*
Clinic Name
*
Phone Number
*
Please enter a valid phone number.
Are you currently receiving financial/patient assistance?
*
Yes
No
Insurance Information
PRIMARY INSURANCE INFORMATION
Primary Insurance
*
Primary Subscriber Name
*
Primary Subscriber's Relationship to Patient (If you are the primary subscriber, please write "self.")
*
Primary Subscriber's Date of Birth
*
/
Month
/
Day
Year
Date
Primary Insurance ID # (include alpha prefix, if applicable)
*
Primary Group #
*
Do you have secondary insurance?
Yes
No
SECONDARY INSURANCE INFORMATION
Secondary Insurance
*
Secondary Subscriber Name
*
Secondary Subscriber's Relationship to Patient (If you are the secondary subscriber, please write "self.")
*
Secondary Insurance ID #
*
Secondary Group #
*
Communication
Please read statement regarding TriState communications and choose one option.
I hereby authorize TriState Health to contact me via my provided email for TriState related marketing communications. Treatment is not conditioned upon my authorization to agree to receive marketing communication and my authorization shall remain effective until canceled by me in writing to TriState Health.
I agree
I do not agree
Market Research Questions
**OPTIONAL: Please answer one question below about how you heard about TriState Health.
How did you hear about us? Please choose all that apply:
Word of Mouth
TV Commercial
Lewiston Morning Tribune
Billboard
Community Event
Facebook
Other
Please list below what other way you heard about us:
Submit
Should be Empty: