[Name of Practice]

REGISTRATION FORM

(Please Print)
Today’s date:	PCP:
PATIENT INFORMATION
Patient’s last name:	First:	Middle:	Mr. Mrs.	Miss Ms.	Marital status (circle one)
Single / Mar / Div / Sep / Wid
Is this your legal name?	If not, what is your legal name?	(Former name):	Birth date:	Age:	Sex:
Yes	No	/ /	M	F
Street address:	Social Security no.:	Home phone no.:
( )
P.O. box:	City:	State:	ZIP Code:
Occupation:	Employer:	Employer phone no.:
( )
Chose clinic because/Referred to clinic by (please check one box):	Dr.	Insurance Plan	Hospital
Family	Friend	Close to home/work	Yellow Pages	Other
Other family members seen here:
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:	Birth date:	Address (if different):	Home phone no.:
/ /	( )
Is this person a patient here?	Yes	No
Occupation:	Employer:	Employer address:	Employer phone no.:
( )
Is this patient covered by insurance?	Yes	No
Please indicate primary insurance	[Insurance]	[Insurance]	[Insurance]	[Insurance]	[Insurance]
[Insurance]	[Insurance]	[Insurance]	Welfare (Please provide coupon)	Other
Subscriber’s name:	Subscriber’s S.S. no.:	Birth date:	Group no.:	Policy no.:	Co-payment:
/ /	$
Patient’s relationship to subscriber:	Self	Spouse	Child	Other
Name of secondary insurance (if applicable):	Subscriber’s name:	Group no.:	Policy no.:
Patient’s relationship to subscriber:	Self	Spouse	Child	Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):	Relationship to patient:	Home phone no.:	Work phone no.:
( )	( )
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims.
Patient/Guardian signature	Date