Greensboro Medical Associates Patient Registration

Greensboro Medical Associates Patient Registration

Please complete this form to register as a patient for medical clinic intake.
Patient Information
Registration Date*

MonthDayYear
Date
Last Name*
First Name*
Middle Name
Address*
Apartment/Unit
City*
State*
ZIP Code*
Primary Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Social Security Number*
Referring Physician
Marital Status
MaleFemaleOther
Age
Race
Religion
Primary Care Physician Name
Primary Care Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider and Appointment Information
Scheduled Provider You Are Scheduled To See*
Phone callTextEmail
Patient Email Address*
example@example.com
Employment Information
Employer*
Employer Address
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Information
Spouse's Name
Spouse's Employer
Spouse's Employer Address
Spouse's Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Consents and Authorizations
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY INSURANCE*
Authorization to Release Medical Information - Date*

MonthDayYear
Date
I AUTHORIZE MY INSURANCE COMPANY TO MAKE PAYMENT OF ANY MEDICAL BENEFITS TO THE PROVIDER OF SERVICES, GREENSBORO MEDICAL ASSOCIATES*
Assignment of Insurance Benefits - Date*

MonthDayYear
Date
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR MY MEDICAL CARE. MY INSURANCE WILL BE FILED AS A COURTESY.
Should be Empty:

Greensboro Medical Associates Patient Registration

Patient Information

Provider and Appointment Information

Employment Information

Spouse Information

Consents and Authorizations