Get Nj Spine Center New Patient Registration

Filling out the NJ Spine Center New Patient Registration form online is an essential step in ensuring efficient care. This guide provides you with comprehensive instructions to complete the form accurately, allowing for a smooth registration process.

Follow the steps to complete the registration form effectively.

1. Click ‘Get Form’ button to obtain the registration form and open it in the editor.
2. Begin by entering your full name in the designated field, ensuring accuracy as this will be used for identification purposes.
3. Provide your date of birth in the specified format, as this helps the clinic to confirm your age and identity.
4. Indicate your gender by selecting the appropriate option from the provided choices.
5. Fill out your complete address, including street, city, state, and zip code to ensure correspondence reaches you.
6. Select your marital status by checking the appropriate box or writing it in if it’s not listed.
7. Enter your social security number in the designated field to assist in insurance processing.
8. Provide your email address to receive updates and communication from the NJ Spine Center.
9. Complete the driver's license number section if applicable, ensuring it matches your official ID.
10. Enter your home and mobile phone numbers for contact purposes.
11. List your primary physician's name and business phone number for referrals and coordination of care.
12. If applicable, fill in the information for your referring physician.
13. In the section regarding emergency contact, provide an emergency phone number and the relation to the patient.
14. If you are under 18 years of age, include the guarantor's information, such as their name, relationship, and contact details.
15. Indicate your employment status and, if applicable, provide details related to an injury including insurance carrier and claim number.
16. For insurance details, specify if primary or secondary insurance is the same as the patient or guarantor.
17. In the medical history section, check off any conditions or allergies that apply to you.
18. Complete the social history section, indicating lifestyle factors such as smoking and alcohol use.
19. Review the consent to treatment and HIPAA sections, ensuring you understand the implications before signing.
20. Finally, after reviewing all filled sections for accuracy, save the completed document. You may then email it as an attachment to appointments@njspinecenter.com or fax it to 973-635-3137.

Complete your NJ Spine Center New Patient Registration form online today to facilitate your initial appointment.