Get Integrapy Patient Registration Form 2020-2025

Filling out the Integrapy Patient Registration Form online is a straightforward process that helps to gather essential information for your visit. This guide will walk you through each section, ensuring that you complete the form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the patient registration form and open it in your preferred online editor.
2. Begin with the 'Today’s Date' field, entering the current date. Indicate who referred you to the practice, providing the name of the referrer.
3. Fill out the CLIENT INFORMATION section carefully. Start with your last name and first name, then indicate if this is your legal name. If it's not, provide your legal name in the space provided.
4. Complete the remaining fields in CLIENT INFORMATION, including your middle name, birth date, age, marital status, address, phone numbers, occupation, and employer. Be sure to include your social security number.
5. In the section regarding why you chose the clinic, select the appropriate box that reflects your reason for visiting. If you have other family members who are patients, please list their names.
6. Select your payment method for today’s visit from the available options: cash, cheque, credit card, or debit card.
7. Proceed to the INSURANCE INFORMATION section. Provide details regarding the person responsible for the bill, including their birth date and address if different from yours.
8. Indicate if this individual is a patient and fill in their occupation and employer information as required.
9. Next, answer the question regarding whether you are covered by insurance and provide details about your primary insurance plan. Include subscriber information, policy numbers, and your relationship to the subscriber.
10. If you have secondary insurance, repeat the process for this insurance, providing the necessary subscriber details.
11. In the IN CASE OF EMERGENCY section, list the name and relationship of a local friend or relative who can be contacted if needed. Include their phone numbers.
12. Finally, read the declaration statement regarding the accuracy of the information provided, then print your name and provide the required signature, along with the date.

Complete your documentation online to ensure a seamless registration process.