Patient Registration
First Name: Last Name: Middle Initial: Preferred Name:
Patient is: Policy Holder Responsible Party
Responsible Party (if someone other than the patient):
First Name: Last Name: Middle Initial:
Address: Address 2:
City: State: Zip:
Home Phone: Work Phone: Ext: Mobile:
Birth Date: Social Security: Drivers License:
Responsible Party is also a Policy Holder for Patient
Patient Information:
Sex: Male Female | Marital Status: Married Single Divorced Separated Widowed
Birth Date: Age: Social Security: Drivers License:
Email: I would like to receive correspondence via email.
I would like to receive appointment reminders via text messages sent to my mobile phone.
Employment Status: Full Time Part Time Retired
Student Status: Full Time Part Time
Medicaid ID:
Employer ID:
Carrier ID:
I was referred by:
Emergency Contact:
Emergency Contact #:
Preferred Pharmacy:
Dental Insurance Information:
Name of Insured: Relationship to Insured: Self Spouse Child Other
Insured Social Security: Insured Birth Date:
Employer:
Address:
Address 2:
City, St, Zip:
Insurance Company:
Contract# / Member ID:
Group #:
Customer Service #:
Rem. Benefits: Rem. Deduct:
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT*
I acknowledge that I have received a copy of this office's Notice of Privacy Practices.
Patient Signature: Enter Name: Date:
