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Kimball Clinic Visit Pre-Registration
This form is to send us pertinent information about your health status prior to or following your clinic visit. By submitting needed information you help us keep your health records up-to-date and accurate.
Please complete the following information. This form should take several minutes to complete. Please give us at least 24 hours to process your submission.
*	Patient Full Name First Name, Middle Initial, Last Name
*	Primary Physician
*	Street Address Full Street Address, City, State, Zip
*	County
*	Telephone Area Code and 7 Digit Number
*	Date of Birth
*	Marital Status	Single     Married     Divorced
*	Sex	Male     Female
	Race	Black     White     Asian     Indian
*	Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number
*	Are you Employed?	Yes     No
	Employer Name If employed list your major employer's business name.
	Employer Address
	Employer Phone Number Area code plus 7 digit number
	Type of Position	Full Time     Part Time     Other
	Occupation
	Retirement Date Fill in this field only if you expect to retire.
*	How Do You Plan To Pay Your Bill?	Insurance     Cash     Medicaid     Medicare
	Responsible Party Information
	Person Responsible for Bill Full Name of Individual or Employer (for Worker's Comp)
	Responsible Party Date of Birth
	Responsible Party Address Mailing Address
	Responsible Party Telephone Area Code and 7 Digit Number
	Relationship to Patient
	Responsible Party SSN Nine Digit Social Security Number
	Responsible Party Employer If employed list your major employer's business name and address
	Employer Phone Number Area Code Plus 7 Digit Number
	Responsible Party's Occupation
*	Person to Notify in Case of an Emergency Please type in full name, relationship, address, area code & telephone number
	Insurance Numbers Please include your primary and secondary insurance numbers or Medicare and Medicaid numbers. Make sure you include your group number or Medicare number. Also list your effective date of coverage.