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Patient Registration Form Template

This document contains a registration form for a medical practice that collects patient information such as name, address, insurance details, emergency contacts, and a signature. It requests demographic information, insurance details, and emergency contact information from the patient. The patient signs acknowledging financial responsibility and authorizing release of information.

Uploaded by

amanda05700
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© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
61 views

Patient Registration Form Template

This document contains a registration form for a medical practice that collects patient information such as name, address, insurance details, emergency contacts, and a signature. It requests demographic information, insurance details, and emergency contact information from the patient. The patient signs acknowledging financial responsibility and authorizing release of information.

Uploaded by

amanda05700
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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[Name of Practice]

REGISTRATION FORM
Todays Date:

PCP: [PCP]
PATIENT INFORMATION

Patients last name: [Last Name]


First: [First Name]
Middle: [Initial]
[Choose an item]

Is this your legal name?

Yes

No

Marital status: [Choose an item]

If not, what is your legal


name?

Former name:

[Legal Name]

[Former Name]

Birth date:

Age:

Sex:

[Age]

Address: [Address/ P.O Box, City, ST ZIP Code]


Social Security no.:

Home phone no.:

Cell phone no.:

[SS#]

[Phone]

[Phone]

Occupation:

Employer:

Employer phone no.:

[Occupation]

[Employer]

[Phone]

Chose clinic because/referred to clinic by (Please choose


one option):

[Doctors name]
[Choose an item]

Other family members seen here: [Other patients]


INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for
bill:

Birth date:

[Responsible party]
Is this person a patient
here?

Yes

No

Address (if different):

Home phone no.:

[Address]

[Phone]

Is this patient covered by insurance?

Yes

No

Occupation:

Employer:

Employer address:

Employer phone no.:

[Occupation]

[Employer]

[Address]

[Phone]

Please indicate primary insurance: [Choose an item]


Subscribers name:

Subscribers S.S. no.:

[Name]

[SS#]

Patients relationship to subscriber: [Choose an item]

| Other: [Other insurance]


Birth date:

Group no.:

Policy no.:

Co-payment:

[Group #]

[Policy #]

$[Co-pay]

| Other: [Relationship to subscriber]

Name of secondary insurance (if applicable):

Subscribers name:

Group no.:

Policy no.:

[Secondary Insurance]

[Name]

[Group #]

[Policy #]

Patients relationship to subscriber: [Choose an item]

| Other: [Relationship to subscriber]


IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

[Friend or relative name]

[Relationship]

[Phone]

[Phone]

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I
understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any
information required to process my claims.

Patient/Guardian signature

Date

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