Patient’s Registration Form

PATIENT’S REGISTRATION FORM

First Name: *

Middle Name:

Last Name: *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Home Phone

Cell Phone *

Employer:

Work Phone

SSN# *

Sex: *

DOB: *

Age: *

EMERGENCY CONTACT INFORMATION

Emergency Contact Name:

Relationship:

Phone Number:

PHARMACY INFORMATION

Preferred Pharmacy Name:

Pharmacy Phone Number:

Pharmacy Address:

Apt, suite, etc.

Country

City

State

Zip code

INSURANCE INFORMATION

Name of Insurance Company: *

Name of Primary Insured:

Primary Insured’s DOB:

Primary Insured’s Employer:

Patients Relationship to Primary Insured:

Self

Spouse

Child

Other

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PLEASE COMPLETE IF PATIENT IS LESS THAN 18 YEARS OF AGE: *

Father’s Name

DOB

Phone Number:

Mother’s Name

DOB

Phone Number:

IMPORTANT: * List all allergies to medications: *

In our efforts to comply with the Health Insurance Portability and Accountability Act (HIPPA), we need to be certain that we guard your privacy according to your wishes when it come to your family , friends, and co-workers.

Please check your response to the following:

May we leave a message concerning your appointments with a coworker, receptionist or secretary that regularly answers your calls?

Yes

N/A

May we leave messages on a voicemail at work?

Yes

N/A

You are over the of 18, and still living at home, may we discuss your appointments/treatments with your children, parent or guardian?

Yes

N/A

You are over the of 18, may we discuss your appointments/treatments with your children, parent or guardian?

Yes

N/A

By signing this registration form, I acknowledge receipt of the Absolute Health Family and Urgent Care Clinic, Privacy of Notice. I understand my rights to privacy and know if I have any questions or specific requests that I may direct them to Office Manager.

Printed Name:

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Reset Signature

Today's Date: *

Patient/Guardian Signature

Reset Signature

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Today's Date *