Get Balanced Well Health Center Patient Registration Form 2019-2025

Filling out the Balanced Well Health Center Patient Registration Form online is an essential step in ensuring your visit is smooth and efficient. This guide provides detailed instructions on how to complete each section of the form accurately and comprehensively.

Follow the steps to complete your patient registration form online.

1. Press the ‘Get Form’ button to access the Balanced Well Health Center Patient Registration Form and open it in your preferred editor.
2. Provide your referral information by indicating who referred you to the health center in the designated field.
3. Enter the current date in the 'Date' field to document when you are filling out the form.
4. In the 'Patient Information' section, fill in your full name, email address, and mailing address, including city, state, and zip code.
5. Input your contact numbers in the provided fields for home, work, and cell phone.
6. Complete your date of birth, gender, and marital status by selecting from the options provided.
7. Enter your Social Security number and occupation, followed by your employer's information, including the address and phone number.
8. Fill out the 'Emergency Contact' section, providing the name, relation, and phone number of an individual to contact in case of an emergency.
9. In the 'Accidental Information' section, indicate whether your visit is due to an accident, and specify the type if applicable.
10. In the 'Insurance Information' section, provide the policy holder's name, date of birth, relationship to the patient, and the phone number.
11. State whether you have health insurance or secondary insurance by selecting 'Yes' or 'No' and provide the name of the insurance carrier(s).
12. Read and complete the 'Assignment and Release' section, ensuring you understand your financial responsibility and authorization for your insurance to pay the provider directly.
13. In the 'Medical Information' section, answer questions regarding your current medications, primary care doctor, and any allergies.
14. Provide your surgical history and family history by listing any relevant conditions.
15. Complete the 'Social History' section by indicating your intake levels for cigarettes, alcohol, and caffeine, while also rating your exercise habits.
16. Assess and record any pain and eating habits in the relevant fields.
17. Review the entire form for accuracy, make any necessary edits, and then save your changes.
18. Once completed, download or print the form for your records, or share it with your healthcare provider as needed.

Take a moment to fill out your Balanced Well Health Center Patient Registration Form online today for a seamless healthcare experience.