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Patient Registration Form:
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Name
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First
Last
DOB
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Sex
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Male
Female
Marital Status
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Married
Single
Divorced
Widowed
Maiden Name/ Also Known As (AKA):
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First
Last
SSN:
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Cell Number
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Home Number
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Work Number
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Preferred Phone #
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Cell
Home
Work
Email
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Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian/ Pacific Islander
Hispanic/Latino
White
Other
Preferred Language
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Do you have a Primary Care or Family Physician (PCP)?
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Yes
No
PCP Name
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First
Last
PCP City, State
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PCP Phone Number
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How did you hear about our office
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My Physican/Doctor's office
Relative/ Friend
Mailing
Walk In/ Drive by
Insurance Network
Hospital/ ER
Urgent Aid
Other
Name of referring doctor or hospital (if applicable)
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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):
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No, I want my test results only communicated personally to me. If so, initial here:
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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
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Print Patient/ Legal Guardian Name
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Date
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