Get Fastmed Patient Registration Form 2017-2025

Filling out the FastMed Patient Registration Form online is a straightforward process designed to gather essential information for your visit. This guide provides step-by-step instructions to ensure you accurately complete each section of the form.

Follow the steps to successfully complete the FastMed Patient Registration Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter today’s date in the designated field to indicate when you are completing the form.
3. In the patient information section, fill in your name using your first, middle, and last name. Make sure to complete the Social Security Number field if required.
4. Select your gender by checking the appropriate box. Next, enter your date of birth in the required field.
5. Indicate your marital status by checking the relevant box that applies to you.
6. Provide your mailing address, ensuring all lines are filled correctly, including city, state, and zip code. Include your contact numbers, marking the main number as required.
7. In the email address field, provide your email to ensure you receive receipts and healthcare information. This information will remain confidential.
8. Fill in the emergency contact section, providing their name and phone number.
9. Complete the PCP & pharmacy information by providing the name and phone numbers of your primary care provider and preferred pharmacy.
10. Indicate your ethnicity/race and preferred language using the checkboxes and text field.
11. Specify how you heard about FastMed by checking all applicable options.
12. If you have insurance, complete the insurance information section, including the subscriber's name, date of birth, SSN, relation, and employer.
13. For minor patients, fill out the responsible party section with the person's information responsible for the account.
14. If applicable, complete the workers’ compensation authorization section by providing the necessary information.
15. Read and sign the financial policies, payment authorization, acknowledgment of notice of privacy practices, patient choice policy, and consent for medical treatment where indicated.
16. Upon finishing the form, save your changes and download or print the completed document for your records, or share as necessary.

Begin the process today by completing the FastMed Patient Registration Form online.