NEW PATIENT REGISTRATION
Your Health Is our Priority
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
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Year
Email Address
*
Cell Phone
*
Preferred Method of Contact
*
Please Select
E-Mail
Cell Phone
Please select one
Social Security Number
*
File Upload
*
Browse Files
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Choose a file
Please upload your Valid ID (Front & Back)
Cancel
of
Occupation
Sex
*
Male
Female
Current Employer
In Case of Emergency
*
Contact Person
Relationship
*
Mother, Father, Spouse
Contact Number
*
(In Case of Emergency Contact Person)
Primary Care Provider
*
Service(s) Provided
Reason For Referral
*
Date Service Provided
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Is the Patient Under 18 years of Age?
Yes
No
Terms
*
Signature
*
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INSURANCE INFORMATION
Patient Full Name
*
First Name
Last Name
Primary Insurance Policy Holder
*
Please Select
Name of Primary Insured
*
First Name
Last Name
Insurance ID #
*
Insurance Company Name
*
Group Name
Group Number
*
Birth Date of Primary Insured
*
-
Month
-
Day
Year
Date
Primary Insured Relationship to the Patient
*
Insurance Upload
*
Browse Files
Drag and drop files here
Choose a file
Please upload front and back.
Cancel
of
Do you have Secondary Insurance?
Yes
No
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DEBIT/CREDIT CARD AUTHORIZATION
Card Holder's Name
*
First Name
Last Name
Credit Card Type
*
Please Select
MasterCard
VISA
AMEX
Discover
Debit Cards
HSA/FSA Cards
Other
Account #
Security Code
*
Expiration Date
*
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that a no-show fee of $50 applies after a late cancellation (see Clinic Policy), and my credit/debit card will be automatically charged for this fee.
I authorize Elevated Image & Primary Care to charge my credit card for additional services provided to patient, for services not paid by insurance carrier and which are considered concierge services as noted under payment terms and uncovered services. Charges to this credit card may include but are not limited to office visits, phone sessions, paperwork ($15/ page), and late cancellation or no-show fees. I understand my credit/debit card will be automatically charged for these services and I will contact the office prior to my visit if I need to change cards on file.
Signature
*
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