Patient Registration Form
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1
2PATIENT REGISTRATION FORM
ALL sections of this form MUST be completed and signed.
PATIENT INFORMATION
First
Middle
Last
Name
Initial
Name
Street Address
(No PO Boxes)
ZIP
City
County
State
Code
Home
Emergency Contact Person
Social
Birth
Male
Phone
Emergency Contact Phone
Security
Date
Female
Student Status
Employment Status
Marital Status
Full Time
Part Time
Full Time
Retired
Self-employed
Single
Separated
Widowed
Not a Student
Part Time
Not Employed
Married
Divorced
Other
I authorize the release of any medical or mental health information necessary to my insurance company to process
insurance claims. I also request payment of private or governmental benefits to the provider of services.
X
Patient’s or Legal Guardian Signature
Date
Signed
I authorize payment of medical benefits to the provider of services.
X
Insured’s Signature
Date
Signed
RESPONSIBLE PARTY (Person completing and signing this form.)
Same as Patient
First
Middle
Last
Name
Initial
Name
Mailing
Address
ZIP
City
County
State
Code
Home
Social
Birth
Male
Phone
Security
Date
Female
Place of
Work
Email
Employment
Phone
Address
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Parent category: Medical