New Patient Registration Form
Confidential Proprietary Information New Pt Reg Form Dec 2004
PATIENT REGISTRATION FORM
**Today’s Date: ________________________ Clinic Name: _______________________________________
PATIENT INFORMATION: (Please use full legal name, no nicknames)
*Last Name: _____________________________________ *First Name: ___________________________________ Middle Initial: ____________
*Address: _________________________________________________________________________________________________________________
City: ____________________________________________ State: ____________________________ Zip: ______________________
Home Phone #: (________) ________-_______________ *Social Security #: __________________________________________________
*Date of Birth: ____________________ Age: _________ *Sex: _______ Marital Status: ____________ Drivers Lic#: ______________
*Employer Name and Address: _______________________________________________________________________________________________
_______________________________________________________________________ Work Phone #: (________) ____________-_____________
E-mail Address: _________________________________________________________ Cell Phone #: (________) ____________-_____________
Emergency Contact Name: _______________________________________________ Emerg Phone #: (________) ___________-_____________
Please tell us how you heard about us: ________________________________Referred by___________________________________
GUARANTOR INFORMATION: (List person or insured name responsible for bill - use full legal name, no nicknames)
*Relationship of Guarantor to Patient: Self _____ Spouse _____ Parent ______ Other _____________________________
*Last Name: ___________________________________ *First Name: ___________________________________ Middle Initial: _____________
*Address: _________________________________________________________________________________________________________________
City: _____________________________________________ State: ____________________________ Zip: ______________________
Home Phone #: (__________) ______________-_____________________ *Social Security #: __________________________________________
*Date of Birth: _________________________ Age: ________________________ *Sex: Female _______ Male ________
*Employer Name and Address: _______________________________________________________________________________________________
__________________________________________________________________________ Work Phone #: (________)_________-__________
INSURANCE INFORMATION: (Please allow receptionist to photocopy your insurance ID cards)
IF SOMEONE OTHER THAN PATIENT IS THE INSURED PARTY, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS
PRIMARY INSURANCE:
Plan Name : __________________________________________ *Insured’s Name: ___________________________________
Insured’s Social Security #: _____________________________ *Insured’s Date of Birth: ____________________________
*Policy / ID #: _________________________________ *Group #: ________________________ Eff Date: ___________________
Claims Address & Phone: _______________________________________________________________________________________
SECONDARY INSURANCE:
Plan Name : __________________________________________ *Insured’s Name: ___________________________________
*Insured’s Social Security #: _____________________________ *Insured’s Date of Birth: ____________________________
*Policy / ID #: _________________________________ *Group #: ________________________ * Eff Date: ___________________
Claims Address & Phone: _______________________________________________________________________________________
*REQUIRED FIELDS-PLEASE COMPLETE FOR BILLING. *ATTACH COPY OF INSURANCE CARDS.
Please read and sign back of form.
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