General Surgery Patient Registration Form

Patient Information

• Full Name: _________________ Date: _________
• Date of Birth: _____________ Age: ___________
• Social Security #: ___________________________
• Address: ___________________________________
• Phone: (Home) _________ (Cell) ______________
• Email: ____________________________________
• Emergency Contact: _________ Phone: _________

Insurance Information

• Primary Insurance: __________________________
• Policy #: _________________________________
• Group #: __________________________________
• Secondary Insurance: _______________________

Medical History

Current Medications

1. _________________ Dosage: ________________
2. _________________ Dosage: ________________
3. _________________ Dosage: ________________

Allergies

• Medications: _______________________________
• Latex: □ Yes □ No
• Iodine: □ Yes □ No

Previous Surgeries

• Type: _________________ Date: _____________
• Type: _________________ Date: _____________

Current Symptoms

• Primary Complaint: _________________________
• Duration: _________________________________
• Pain Level (1-10): __________________________

Authorization

I hereby authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to the physician.

Signature: _________________ Date: __________

For Office Use Only

Reviewed by: ______________ Date: __________