Get New Patient Registration Form. - Whole Child Wellness

Completing the New Patient Registration Form is an essential step to ensure efficient healthcare services at Whole Child Wellness. This guide provides clear and supportive instructions to help you navigate each section of the form with ease.

Follow the steps to fill out the registration form successfully.

1. Press the ‘Get Form’ button to access the registration form and open it for editing.
2. Fill in the patient’s name and date of birth in the provided fields. Select the appropriate gender option from Male or Female.
3. Enter the home address, city, state, and zip code. Then, provide the home telephone number, mobile number, and work number.
4. Input the email address for contact purposes. If you are a parent completing the form for a minor, you'll need to provide the employer's name and occupation.
5. Indicate the insurance company and the claim mailing address. Enter the insured name along with the relationship to the patient, insurance ID number, and group number.
6. If the patient is a minor, fill in the parent's information, including their name, date of birth, gender, contact information, email address, employer, and occupation.
7. List any siblings that have been seen in the office and indicate who referred you to Whole Child Wellness.
8. Review the authorization sections for integrative medical treatment, additional caregiver authorization, and payment authorization. Provide your initials where indicated and sign at the designated area.
9. Read and understand the cancellation and telephone/email policies, then initial in the appropriate spaces.
10. Acknowledge receipt of the Whole Child Wellness policies and notice of privacy practices by providing your initials and signature.
11. Complete the authorization to release information to the insurance carrier by initialing and signing as required.
12. After filling out all relevant sections, save your changes, then choose to download, print, or share the form as needed.

Complete your New Patient Registration Form online today to initiate your wellness journey with Whole Child Wellness.