Patient Registration Form Template

PATIENT REGISTRATION FORM

Date: Date

Healthcare Facility: Facility/Practice Name

Address: Address Phone: Phone Fax: Fax Website: Website

SECTION 1: PATIENT INFORMATION

Last Name: Last Name

First Name: First Name

Middle Initial: MI

Preferred Name: Preferred Name

Date of Birth: MM/DD/YYYY

Age: Age

Sex Assigned at Birth: Male Female Intersex

Gender Identity: Male Female Non-binary Prefer not to say Other: _______

Preferred Pronouns: He/Him She/Her They/Them Other: _______

Social Security Number: XXX-XX-XXXX (optional in some states)

Driver's License/ID Number: Number

Issuing State: State

Marital Status:

Single Married Divorced Widowed Separated Domestic Partner

Race/Ethnicity (optional, for statistical purposes):

White/Caucasian Black/African American Hispanic/Latino Asian Native American/Alaska Native Native Hawaiian/Pacific Islander Multiracial

Other: _______

Prefer not to answer

Preferred Language: Language

Need Interpreter: Yes No Language: _______

SECTION 2: CONTACT INFORMATION

Home Address:

Street: Street Address Apt/Unit: Apt City: City State: State ZIP Code: ZIP

Mailing Address (if different):

Same as home address Street: Street City: City State: State ZIP: ZIP

Phone Numbers:

Home: Phone Cell: Phone Preferred: Work: Phone Preferred:

Email: Email

Best time to contact: Morning/Afternoon/Evening

OK to leave voicemail: Yes No

OK to contact by email: Yes No

OK to send text messages: Yes No

SECTION 3: EMERGENCY CONTACT

Primary Emergency Contact:

Name: Full Name

Relationship: Relationship Phone: Phone Alternate Phone: Phone Address: Address

Secondary Emergency Contact:

Name: Full Name

Relationship: Relationship Phone: Phone

SECTION 4: INSURANCE INFORMATION

Do you have health insurance? Yes No

PRIMARY INSURANCE:

Insurance Company: Company Name Policy/ID Number: Number Group Number: Number Policy Holder Name: Name Policy Holder DOB: DOB

Relationship to Patient: Self Spouse Parent Other: _______

Policy Holder Employer: Employer Insurance Phone: Phone

SECONDARY INSURANCE (if applicable):

Insurance Company: Company Name Policy/ID Number: Number Group Number: Number Policy Holder Name: Name Relationship to Patient: Relationship

Medicare Number: Number (if applicable)

Medicaid Number: Number (if applicable)

I authorize:

• Direct payment of medical benefits to this provider
• Release of medical information to insurance company for billing purposes

SECTION 5: RESPONSIBLE PARTY (If Different from Patient)

Financially Responsible Party:

Name: Full Name

Relationship to Patient: Relationship Date of Birth: DOB SSN: SSN Address: Address Phone: Phone Employer: Employer Employer Phone: Phone

SECTION 6: REFERRING PHYSICIAN/HOW DID YOU HEAR ABOUT US?

Referred by:

Primary care physician: Name Specialist: Name and specialty Friend/Family member: Name Insurance company Online search Advertisement Hospital

Other: _______

Primary Care Physician (if different from referral):

Name: Physician Name

Practice: Practice Name Phone: Phone Fax: Fax Address: Address

May we contact your PCP: Yes No

SECTION 7: REASON FOR VISIT

Chief Complaint/Reason for Today's Visit:

Description

When did symptoms start: Date/Timeframe

Is this visit related to:

Work injury (Workers' Compensation) Auto accident Other injury Routine care Follow-up New problem Annual physical/wellness visit

If work injury, employer: Employer Name

If auto accident, date of accident: Date

Auto insurance company: Company

Claim number: Number

SECTION 8: MEDICAL HISTORY

Do you have or have you had any of the following? (Check all that apply)

Cardiovascular:

High blood pressure Heart disease Heart attack Stroke High cholesterol Heart murmur Irregular heartbeat

Respiratory:

Asthma COPD/Emphysema Sleep apnea Tuberculosis

Endocrine:

Diabetes (Type 1/Type 2) Thyroid disease Osteoporosis

Gastrointestinal:

GERD/Reflux Ulcers Irritable bowel syndrome Crohn's disease/Colitis Liver disease Hepatitis (Type: ___)

Neurological:

Seizures/Epilepsy Migraines Multiple sclerosis Parkinson's disease Dementia

Mental Health:

Depression Anxiety Bipolar disorder PTSD

Other: _______

Other Conditions:

Cancer (Type/Year: _______)

Kidney disease Anemia/Blood disorder Arthritis Autoimmune disease HIV/AIDS Chronic pain

Other medical conditions not listed:

Description

Previous Surgeries:

Surgery: Type Year: Year Surgery: Type Year: Year Surgery: Type Year: Year

Hospitalizations:

Reason: Reason Year: Year Reason: Reason Year: Year

SECTION 9: CURRENT MEDICATIONS

Please list ALL medications you currently take, including over-the-counter and supplements:

1. Medication: Name Dose: Dose Frequency: How often Reason: Why taking 2. Medication: Name Dose: Dose Frequency: How often Reason: Why taking 3. Medication: Name Dose: Dose Frequency: How often Reason: Why taking 4. Medication: Name Dose: Dose Frequency: How often Reason: Why taking 5. Medication: Name Dose: Dose Frequency: How often Reason: Why taking

No current medications See attached list

SECTION 10: ALLERGIES

Allergies to Medications:

Medication: Name Reaction: Reaction Medication: Name Reaction: Reaction Medication: Name Reaction: Reaction

Other Allergies:

Latex Iodine/Contrast dye Adhesive/Tape Food allergies: List Environmental allergies: List

No known allergies

SECTION 11: SOCIAL HISTORY

Tobacco Use:

Never Former smoker - Quit date: Date Amount: packs/day for X years Current smoker - Amount: packs/day Vape/E-cigarette - Frequency: Frequency

Alcohol Use:

None Occasional (less than 3 drinks/week) Moderate (3-7 drinks/week) Heavy (more than 7 drinks/week)

Recreational Drug Use:

None Current or past use: Type and frequency

Caffeine: Cups/day

Exercise: Frequency and type

Occupation: Job title

Employer: Employer name

Living Situation:

Live alone Live with spouse/partner Live with family Assisted living

Other: _______

SECTION 12: FAMILY HISTORY

Do any blood relatives have or have had:

Heart disease - Relationship: Relationship Stroke - Relationship: Relationship Diabetes - Relationship: Relationship High blood pressure - Relationship: Relationship Cancer - Type: Type Relationship: Relationship Mental illness - Relationship: Relationship Other hereditary conditions: Condition Relationship: Relationship

Mother: Age: Age/Deceased at age Health status: Status/Conditions

Father: Age: Age/Deceased at age Health status: Status/Conditions

SECTION 13: FOR WOMEN ONLY

Are you currently pregnant? Yes No Unsure

Could you be pregnant? Yes No

Are you breastfeeding? Yes No

Date of last menstrual period: Date

Are your periods regular? Yes No

Number of pregnancies: Number

Number of live births: Number

Number of miscarriages/abortions: Number

Birth control method: Method or None

Date of last mammogram: Date

Date of last Pap smear: Date

SECTION 14: ADVANCE DIRECTIVES

Do you have:

Living Will Healthcare Power of Attorney/Healthcare Proxy Do Not Resuscitate (DNR) order POLST (Physician Orders for Life-Sustaining Treatment) None

If yes, would you like to provide a copy for our records? Yes No

Healthcare Power of Attorney/Decision Maker:

Name: Name

Relationship: Relationship Phone: Phone

SECTION 15: CONSENT AND ACKNOWLEDGMENTS

I acknowledge and consent to the following:

Assignment of Benefits:

I assign payment of authorized benefits to this provider for services rendered

Financial Responsibility:

I understand I am financially responsible for all charges, whether or not covered by insurance I understand I am responsible for copays, deductibles, and non-covered services

Release of Information:

I authorize release of medical information to my insurance company and other healthcare providers as needed for treatment, payment, and healthcare operations

Medicare/Medicaid (if applicable):

I certify that the information I have provided is correct and I authorize release of medical information necessary to process claims

Privacy Practices:

I acknowledge receipt of Notice of Privacy Practices (HIPAA) I was offered a copy of the Notice of Privacy Practices

Consent to Treat:

I consent to medical treatment by this provider and authorized staff

Communication:

I consent to appointment reminders and health information via phone, email, or text

Accuracy of Information:

I certify that the information I have provided is complete and accurate to the best of my knowledge I agree to notify the office of any changes to this information

SIGNATURES:

Patient (or Parent/Guardian if minor):

Signature: _______________________

Printed Name: Name

Date: _______________________

If signed by someone other than patient:

Relationship to Patient: Relationship Legal Authority: Parent/Guardian/POA/Other

Staff Member Verifying Information:

Signature: _______________________

Printed Name: Name

Date: _______________________

FOR OFFICE USE ONLY:

Registration Date: Date

Registered By: Staff Name

Patient ID Assigned: ID Number

Insurance Verified: Yes No By: Name Date: Date

Copay Collected: Amount

Photo ID Verified: Yes No

Insurance Card Copied: Yes No

Notes: Any relevant notes