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New Patient Registration
Welcome to GNI. We need to collect some important information about you. If you need any assistance, please ask. It is our pleasure to help you. We want you visit with GNI to be comfortable, efficient and meet all of your healthcare needs.
Basic Demographics
Name
*
Mr.
Ms.
Mrs.
Dr.
Prefix
First Name
Middle Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred Method (s) of Contact
*
Cell Phone-Calling
Cell Phone-Texting
Email
Home Phone
Business Phone
Email:
*
example@example.com
Cell Phone Number
Format: (000) 000-0000.
Home Phone Number
Format: (000) 000-0000.
Business Phone Number
Format: (000) 000-0000.
Date of Birth
*
/
Month
/
Day
Year
Don't worry, you're still young at heart
Age
Gender
*
Female
Male
Transgender Female
Transgender Male
Gender Variant/Non-Conforming
Prefer Not To Say
Social Security #:
*
Your social security number is stored only for PHI/financial reasons. It is considered sensitive and protected with the highest level of security
Your Employer:
Employer Phone
Format: (000) 000-0000.
Preferred Language
We are now required to collect race, ethnicity and preferred language. You may choose to prefer not to answer.
Race/Ethnicity
American Indian or Alaska Native
English
Asian
Hispanic or Latino
Spanish
Black or African American
White/Caucasian
Native Hawaiian or Other Pacific Islander
Prefer not to answer
Other
Your Employer:
Tell us who you work for
Company Name:
Occupation:
Employer Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Years Employed
Employer Phone #
Format: (000) 000-0000.
Spouse/Parent
(person to be billed as responsible party or if patient under 18)
Spouse or Parent
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Insured's Social Security #:
Your social security number is stored only for PHI/financial reasons. It is considered sensitive and protected with the highest security
Spouse/Insured Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Insured's Phone Number
Format: (000) 000-0000.
Insured's Employer Name:
Insured's Occupation:
Insurance Information
If anything not applicable, you may leave blank
Primary Insurance Name:
Insurance Phone Number
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Member ID #
Group ID #
Effective Date
-
Month
-
Day
Year
Date
Relationship to Insured:
Subscriber DOB
-
Month
-
Day
Year
Date
Is this health insurance a benefit of employment?
Yes
No
Auto
Not Sure
Other
Secondary Insurance Name:
Secondary Insurance Phone Number
Format: (000) 000-0000.
Secondary Insurance Subscriber's Name
First Name
Last Name
Secondary Member ID #
Secondary Group ID #
Secondary Effective Date
-
Month
-
Day
Year
Date
Secondary Insurance Relationship to Insured:
Secondary Insurance Subscriber DOB
-
Month
-
Day
Year
Date
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Referring Physician Information
Let us know who referred you to GNI
I have a referring physician, listed below
My PCP is my referring physician
I do not have a referring physician/self-referred
I do not have a care physician/PCP
Referring Physician Name
Dr.
Mrs.
Mr.
Ms.
Prefix
First Name
Last Name
Referring Physician Phone #:
Format: (000) 000-0000.
Primary Care Physician:
Tell us who treats you regularly or your family physician
Primary Care Physician Name
Dr.
Mrs.
Mr.
Ms.
Prefix
First Name
Last Name
Primary Care Physician Phone #:
Format: (000) 000-0000.
Primary Care Physician Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Pharmacy Information:
Tell us where you fill your medications
Pharmacy Name:
Pharmacy Phone Number
Format: (000) 000-0000.
Pharmacy Address (if known)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency & Records Contact Information:
Tell us who to contact in an emergency or who to give protected health information to
Emergency Contact
First Name
Last Name
Emergency Contact Relationship
Spouse/Significant Other
Parent
Child (Daughter/Son)
Family Member
Friend
Emergency Contact Phone
Format: (000) 000-0000.
Authorized Contacts for Release of Information
Authorized Contact is same as Emergency contact listed above
Authorized Contact
First Name
Last Name
Authorized Contact Relationship
Spouse/Significant Other
Parent
Child (Daughter/Son)
Family Member
Friend
Authorized Contact #2
First Name
Last Name
Authorized Contact #2 Relationship
Spouse/Significant Other
Parent
Child (Daughter/Son)
Family Member
Friend
Information Only to be released to Authorized Contacts listed above:
Medical Information (health diagnosis, treatment, etc)
Financial Information (balance due, payments, insurance)
Prescription Pickup
Documentation Pickup
May we leave a voicemail containing medical/personal information?
Yes
No
Take A Photo of Any Insurance/License/Supporting Documentation (flat surface on dark background works best)
Take A Photo of Any Insurance/License/Supporting Documentation_2 (flat surface on dark background works best)
Take A Photo of Any Insurance/License/Supporting Documentation_3 (flat surface on dark background works best)
Upload Additional Files
Browse Files
Use this to include any additional files/forms you'd like with your chart
Cancel
of
Patient Signature:
Please sign below
*
Date:
/
Month
/
Day
Year
Date
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Tell Us Who You'd Like to See/Reason for Visit
Tell Us Briefly About Your Reason for Visit
*
Neurosurgery
Comprehensive Vascular Neurosurgery
Mandy-Jo Binning, MD
Zakaria Hakma, MD
Hirad Hedayat, MD
Kenneth Liebman, MD
Tina Loven, MD
Jonathan Thomas, MD
Atom Sarkar, MD
Scott Strenger, MD
Erol Veznedaroglu, MD
I'm not sure
Neurosurgery
Neurosurgery
I'd like to see a neurosurgeon but I don't know who I need
Other
Neurology
Rima Alkasem, MD
Ausim Azizi, MD
Brian Kelly, MD
Jill Farmer, MD
Krikor Tufenkjian, MD
Neurology
I'd like to see a neurologist but I don't know who I need
Other
Neuropsychology
Kathryn Lester, PsyD
Jennifer L. Gallo, PhD
I'm not sure
Neuropsychologist
I'd like to see a neuropsychologist but I don't know who I need
Other
Are you open to seeing a physician/provider via Telemedicine?
Yes
No, prefer in-person visit only
Other
How did you hear about our practice, GNI?
*
Referral-my current physician
Referral-friend/colleague
Referral-recent hospital discharge/ER
Online (e.g. Crozer website)
Online (e.g. GNI Website)
Online-Search Engine (e.g. Google)
Online-Social Media
Billboard
Other
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Submit
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