Registration Form

Section I:Patient InformationDate:

Name: I Prefer to be called:

Address: City: State: Zip:

Phone:() Work Phone () Cell Phone ()

OK to leave message on recorder Yes No

Date of Birth: Social Security Number:

Check Appropriate Box: Minor Single Married Widowed Seperated Divorced

If Student, Name of School City/State FT PT

Spouse or Parent’s Name: Employer: Work Phone

How did you hear about us : Newspaper Internet Family/Friend Other

Person to contact in case of emergency Phone

Email Address

Section II:Responsible Party

Relationship to Patient: Self Spouse Parent Other

Name: Birthdate:

Address:

City: State: Zip: Phone:()

Employer: Work Phone:() SSN#

Section III:Insurance Information

Name: DOB: Relationship to Patient:

SSN#: Name of Employer: Work Phone:()

Address of Employer: City: State: Zip:

Insurance Company: GRP#: ID#:

Ins Co Address:: Ins Co. Phone:

------- DO YOU HAVE ANY ADDIONAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING -------

Name of Insured: DOB Relationship to Patient

SSN#: Name of Employer: Work Phone:()

Address of Employer: City: State: Zip:

Insurance Company: GRP#: ID#:

Ins Co Address:: Ins Co. Phone:

THE RECEPTIONIST WILL ASK FOR YOUR INSURANCE CARDS AND COPAYMENT AT EVERY VISIT.