Get Patient Registration Form

Filling out the Patient Registration Form online is a straightforward process that helps streamline your experience at the healthcare facility. This guide will provide step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the Patient Registration Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your full name in the designated field labeled 'Patient Name'.
3. Fill in your Social Security Number in the provided format, using dashes to separate the digits.
4. Input your date of birth by selecting the month, day, and year from the appropriate fields.
5. Indicate your sex by circling 'M' for male or 'F' for female.
6. Select your marital status by checking either 'Married', 'Single', 'Divorced', or 'Widow'.
7. Complete your address, including street, city, state, and zip code.
8. Provide your home phone number and email address in the respective sections.
9. Choose whether you wish to receive communications through your email by marking 'Yes' or 'No'.
10. Enter your employer's name and corresponding phone number, followed by your employer's address.
11. Identify your primary care physician, including their name and copay amount.
12. State how you heard about the practice in the provided space.
13. If applicable, fill out the section for the person responsible for the bill with their name and Social Security Number.
14. Indicate the relationship of the guarantor to you by checking the relevant box.
15. Provide the guarantor's date of birth, address, and phone number.
16. Complete the employer information for the guarantor, including name, phone number, and address.
17. In the emergency contact section, list the name, address, home and work phone numbers, and relationship for the person to contact in case of an emergency.
18. For insurance information, fill in the first insurance details, including plan name, ID number, address, group number, policy holder information, and effective date.
19. Repeat the previous step for additional insurance information if applicable.
20. Indicate whether your visit is related to a job injury or automobile accident by selecting 'Yes' or 'No'.
21. Authorize the release of medical information by signing and dating the form at the bottom.
22. Once completed, review the form for accuracy, then save your changes, download, print, or share the form as needed.

Complete your Patient Registration Form online today to ensure a smooth healthcare experience.