Patient Registration Form

Name

First NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

MonthDayYear

Social Security #

Home Phone

Please add your home phone numberFormat: (000) 000-0000.

Cell Phone

Please add your cell phone or best day time phone numberFormat: (000) 000-0000.

Do you prefer we contact you by your home or cell phone?

May we leave a message regarding your medical care and test results?

Email Address

example@example.com

Emergency Contact:

Name* Phone Number* Relationship*

Primary Care Physician

Pharmacy Name & Location

Responsible Party - If the patient is a minor (under 18 years of age)

Name Date of Birth Relationship to patient

Insurance Information

PRIMARY MEDICAL INSURANCE - SECONDARY MEDICAL INSURANCE - VISION INSURANCE

Insurance Company Name

Policy Holder Name

Policy Holder DOB

Policy Holder Social Security #

Patient Relationship to Policy Holder

How did you hear about us?

If you were referred by a friend or relative, please name them:

I understand that I am responsible for all financial obligations of health services and reimbursement and payment of claims from my insurance company. If for any reason the account should become delinquent, I agree to pay for all billing charges, interest charges, collection costs, and reasonable legal fees.

Patient Signature

Date

MonthDayYear