New Patient Registration Form

Patient Information

• Full Legal Name: ________________________
• Date of Birth: //____
• Social Security Number: --___
• Gender: □ Male □ Female □ Other: ________
• Marital Status: □ Single □ Married □ Divorced □ Widowed

Contact Information

• Street Address: ________________________
• City: ____________ State: ___ ZIP: _______
• Home Phone: ()-_____
• Mobile Phone: ()-_____
• Email: ________________________________
• Preferred Contact Method: □ Phone □ Email □ Text

Emergency Contact

• Name: ________________________________
• Relationship: __________________________
• Phone: ()-_____

Insurance Information

Primary Insurance

• Insurance Company: _____________________
• Policy Number: ________________________
• Group Number: ________________________
• Policy Holder Name: ____________________
• Relationship to Patient: _________________

Medical History

• Primary Care Physician: _________________
• Previous Medical Conditions: _____________
• Current Medications: ___________________
• Allergies: ____________________________

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: //____

Office Use Only

• Patient ID: ___________________________
• Received By: _________________________
• Date Processed: //____