Patient Registration Form

Patient Information
Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Primary contact numbers
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Mailing address
City
State
ZIP
Apt#
Street
Basic
Best time to reach you:
Home Address (If Different from Mailing)
City
State
ZIP
Apt#
Street
Interpreter Needed?
We are requesting the following information of all patients in order to understand our patient needs better, to help our staff use the most respectful language when addressing you, and for funding purposes that may help reduce the cost of your care.
Gender at Birth
Preferred Gender/Gender Identity
Ethnicity
Housing Status
Sexual Orientation
Student
Race
How did you hear about us?
Employment Status
Are you a:
Do you have a(n):
Veteran?
Advanced Directive?
Board Member?
Living Will?
BCHN Employee?
Emergency Contact Information
Full Name
Relationship
Address
Phone Number
Format: (000) 000-0000.
Insurance Information
Primary Insurance Name
Policy #
Name of the Insured
DOB of Insurance Holder
Patient’s Relationship to the Insured
Secondary Insurance Information
Secondary Insurance Name
Policy #
Name of the Insured
DOB of Insurance Holder
Patient’s Relationship to the Insured
Name of Primary Care Provider on the card
PCP Address
Other healthcare providers
Should be Empty: