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PATIENT REGISTRATION

Symptoms*

Patient's Last Name*

Patient's First Name*

Patient's Middle Initial

Patient's Mailing Address*

Phone Number (Home, Work, Cell)*

Patient's Date of Birth (MM/DD/YYYY)*

Patient's Gender

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Patient's Marital Status

Patient's Race

Patient's Ethnicity

Patient's Preferred Language

Patient's Email Address

Responsible Party's Last Name

Responsible Party's First Name

Responsible Party's Middle Initital

Responsible Party's Mailing Address

Phone Number (Home, Work, Cell)

Date of Birth (MM/DD/YYYY)

Responsible Party's Gender

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Responsible Party's Marital Status

Responsible Party's Relationship to Patient

Insurance

Insurance Policy Holder's Subscriber ID#

Insurance Policy Holder's Group#

Insurance Policy Holder's Last Name

Insurance Policy Holder's First Name

Insurance Policy Holder's Middle Initial

Insurance Policy Holder's Date of Birth (MM/DD/YYYY)

Insurance Policy Holder's Gender

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Insurance Policy Holder's Marital Status

Insurance Policy Holder's Relationship to Patient

Emergency Contact Full Name*

Emergency Contact Phone #*

Emergency Contact Relationship to Patient*

In case of an emergency, do we have permission to contact the person listed above?*

Select an option

I certify that the information provided above is completed and accurate to the best of my knowledge*

Select an option

Signature of Patient/Patient Representative*

Date*

CONSENT FOR TREATMENT OF AN ADULT (Printed Name of Client/Legal Representative)*

CONSENT FOR TREATMENT OF AN ADULT (Witness Date)*

CONSENT FOR TREATMENT OF A DEPENDENT (Printed Name of Client/Legal Representative))*

CONSENT FOR TREATMENT OF A DEPENDENT (Witness Date)*

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