Patient Registration Form

Patient Registration Form:

* Indicates required field

Name *

First

Last

DOB *

Sex *

Male Female

Marital Status *

Married Single Divorced Widowed

Maiden Name/ Also Known As (AKA): *

First

Last

SSN: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Number *

Home Number *

Work Number *

Preferred Phone # *

Email *

Race *

Preferred Language *

Do you have a Primary Care or Family Physician (PCP)? *

Yes No

PCP Name *

First

Last

PCP City, State *

PCP Phone Number *

How did you hear about our office *

Name of referring doctor or hospital (if applicable) *

Consent to treatment and release of information:

Unless otherwise directed below, if I am unavailable, the Physician may communicate normal test results via telephone, voicemail, or answering machine to the phone numbers on this form, as long as the nature of the call is not disclosed.

In addition, my normal test result may be communicated to (name and relationship): *

No, I want my test results only communicated personally to me. If so, initial here: *

I authorize examination and medical treatment, verification of benefits and the release of information (including the diagnosis and medical records) to other physicians involved in my care, to my insurance company to facilitate billing and reimbursement, and for quality assurance purposes. I acknowledge that I have been offered and received or declined to receive a copy of the HIPAA Notice of Privacy Practices. I authorize benefits to be paid directly to the Physician and I understand that I am responsible for any unpaid balance under the terms of my insurance policy. Patient/Legal Guardian Signature *

Print Patient/ Legal Guardian Name *

Date *

Submit

Patient Registration Form:

Consent to treatment and release of information:

Phone Hours

Telephone

Fax