Patient Registration Form

Patient Information
Name*
Home Phone*
Cell Phone*
Work Phone *
Primary contact numbers
Home Phone*
Cell Phone*
Work Phone *
Mailing address
City*
State*
ZIP*
Apt#*
Street*
Basic

Ok to leave voice message?
Best time to reach you:*

AMPM
Ok to leave a text message?
Opt out of all Practice Communication
Home Address (If Different from Mailing)
City*
State*
ZIP*
Apt#*
Street*
Interpreter Needed?

YesNo
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?

YesNo
Advanced Directive?

YesNo
Board Member?

YesNo
Living Will?

YesNo
BCHN Employee?

YesNo
Emergency Contact Information
Full Name
Relationship
Address
Phone Number
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
I agree to allow Bronx Community Health Network to contact me regarding my private health information, evaluation, and treatment.
I verify that the information above is correct to the best of my knowledge
Should be Empty:

Patient Information

Primary contact numbers

Mailing address

Home Address (If Different from Mailing)

Emergency Contact Information

Insurance Information

Secondary Insurance Information

Other healthcare providers