Language
English (US)
Spanish (Latin America)
NEW PATIENT FORM
Insurance
Patient's Name
*
First
Middle (optional)
Last
Address
*
Street Address
City
State/Province
Postal/Zip Code
Primary Phone #
*
Please add a valid phone number.
Format: (000) 000-0000.
Secondary Phone #
Please add a valid phone number.
Format: (000) 000-0000.
Work Phone #
Please add a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Social Security # (Optional)
Marital Status
*
Single
Married
Divorced
Widowed
Other
Occupation
Spouse's Name
First
Last
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Primary Phone #
*
Please add a valid phone number.
Format: (000) 000-0000.
Secondary Phone #
*
Please add a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Relationship with Patient
*
Phone #
*
Please add a valid phone number.
Format: (000) 000-0000.
Primary Care Physician
*
Referring Physician
*
Which racial category does the patient most closely identify with?
*
African American
Asian
White
Hispanic
Native American
Native Hawaiian
Pacific Islander
Other
What is the patient's ethnicity?
*
Hispanic
Not Hispanic
What is the patient's preferred language?
*
English
Spanish
Other
Insurance Information
Primary Insurance
*
Policy #
*
Group ID
Date of Birth
*
-
Month
-
Day
Year
Date
Name of the Policy Holder
*
First
Last
Insurance Card Photo (Front)
Insurance Card Photo (Back)
Employer
Employer Address
Street Address
City
State/Province
Postal/Zip Code
Work Phone #
Please insert a valid phone number.
Format: (000) 000-0000.
Secondary Insurance
Policy #
Group ID
Name of the Policy Holder
Date of Birth
-
Month
-
Day
Year
Date
I authorize TEXAS REGIONAL PHYSICIANS, its assignees and third-party collection agents to use the contact information I hove provided to communicate with me and to place calls to my home/cellular/employment telephone, leave voice or text messages and use pre-recorded/artificial/voice/text messages and/or auto- dialing devices in connection with any communication to me.Furthermore, I authorize Texas Regional Clinic to discuss my/ the patient's core with the following persons:
*
Patient Signature
*
Today's Date
-
Month
-
Day
Year
Date
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