Get Patient Registration Form - Mckenzie Family Practice

Completing the Patient Registration Form for McKenzie Family Practice online is essential for ensuring accurate and efficient healthcare services. This guide will provide you with clear, step-by-step instructions to help you navigate through the form with ease.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the registration form and open it for editing.
2. Begin by entering the patient's legal name in the designated fields. Provide the last name, first name, and middle initial. If applicable, enter the preferred name.
3. Fill in the complete address, including street, city, state, and zip code.
4. Next, enter the Social Security Number (SSN) and birthdate in the appropriate fields.
5. Indicate the patient's sex by marking the appropriate checkbox.
6. Provide the patient's employer information along with home, work, and cell phone numbers.
7. Indicate the marital status by selecting one of the options: married, single, divorced, or widowed.
8. If the responsible party is different from the patient, enter their legal name and complete address.
9. Provide the Social Security Number (SSN) and birthdate for the responsible party, along with their sex.
10. Fill in the employer information for the responsible party and provide their contact phone numbers.
11. Specify the relationship of the responsible party to the patient.
12. For insurance information, fill out the primary insurance details, including the insurance company name, ID number, group number, subscriber's name, SSN, and birthdate.
13. If applicable, provide secondary insurance information similarly.
14. Fill in the emergency contact information, including their name, relationship to the patient, and contact numbers.
15. Complete the pharmacy information, including the pharmacy name and location.
16. Review the treatment authorization section, and if you agree, sign and date it.
17. Finally, read the financial agreement and initial where required. Certify your understanding of the terms and sign where it notes 'Responsible Party.'
18. Once all fields are filled in, save your changes, download the completed form, or print it for your records. You may also share it as needed.

Complete your registration by filling out the form online today.