Patient Registration Form "*" indicates required fields * indicates required fieldsToday's Date* MM slash DD slash YYYY Application Type* NEW Patient UPDATE Demographics Patient Name* First Last Birth date* MM slash DD slash YYYY Age*Sex* Male Female Other Marital Status*--Select--SingleMarriedPartneredWidowedDivorcedAddress* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Type* Contact Via*--Select--TextVoicemailNo Message PleaseSecondary PhoneType Contact Via--Select--TextVoicemailNo Message PleaseEmail Address* Is it okay to leave a voice message or text message on your listed phone(s) or email regarding your appointment reminder and/or other medical care?* Yes No Patient Social Security #* Employer* Emergency Contact InformationContact Person* Spouse/Partner Parent/Guardian Spouse/Partner Name* Spouse/Partner Phone*Parent/Guardian Name* Parent/Guardian Phone*Contact Person is?* Primary Emergency Contact Financially Responsible Party Ok to talk to emergency contact regarding personal medical information as covered by HIPAA?* Yes No Secondary Emergency Contact Relationship Secondary Contact PhoneSecondary Contact is Financially Responsible Party Yes No Ok to talk to emergency contact regarding personal medical information as covered by HIPAA? Yes No Other InformationPreferred Pharmacy* City* PRIMARY Medical Insurance Name* PRIMARY Subscriber* Self Spouse/Partner Parent Other PRIMARY Subscriber Date of Birth* MM slash DD slash YYYY SECONDARY Medical Insurance Name PRIMARY Subscriber Self Spouse/Partner Parent Other PRIMARY Subscriber Date of Birth MM slash DD slash YYYY Please circle one from each listRace* American Indian or Alaska Native Asian Black or African American Hispanic White Rather not Report Other Ethnicity* Hispanic or Latino Not Hispanic or Latino Rather not Report Other Primary Language Spoken* English Spanish French Mandarin Other Δ Back to New Patient Forms
