Patient Registration Form

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Patient Registration Form

Please fill out the following form to help us understand your physical condition.

First Name

Last Name

Date of Birth

Sex

Email Address

Social Security #

Address

City

State

Phone Number

Zip Code

In the event that we can not reach you when calling, can we leave a voicemail?

Marital Status *

Single

Married

Divorced

Widowed

Separated

Name of spouse or next of kin

Address of person listed above

Relationship status of person listed above

Phone number of person listed above

Emergency contact (Person outside of your home)

Emergency contact phone number

Emergency contact relationship

Primary care physician

Primary Insurance

Blue Cross

Medicare

Medicad

M Care

Blue Care Network

Health Plus

Commercial Insurance

Worker's Compensation

Genesee Health Plan

Other

If you selected other, please specify your insurance carrier

Insurance Carrier: Please complete the information below for the individual who owns the insurance policy.

Policy Holder Name

ID#

Secondary Insurance

ID#

Policy Holder Date of Birth

Policy Holder Name

Policy Holder Date of Birth

HIPPA Privacy Authorization - I authorize the following person(s) listed below to have access to my Protected Health Information such as: appointments, diagnosis, billing information, testing results, or any other information that may fall under HIPPA

Name

Relationship

Name

Relationship

Name

Relationship

I declare that the info I’ve provided is accurate & complete.

I accept terms & conditions

Thanks for submitting!

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