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To make your registration as fast and easy as possible, please complete and submit the following pre-registration form. |
Please complete the following information at least 48 hours prior to your scheduled visit.
Remember, a copy of your insurance card, driver's license/ID, and signature is needed in order to finalize your office visit.
All information will be kept secure and confidential. |
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Today's Date |
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Patient Information |
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Patient Full Name First Name, Middle Initial, Last Name |
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Date of Birth |
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Sex |
Male Female |
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Age |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Language |
English Spanish Other |
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Race |
Asian Black Indian/Native American Pacific/Hawaiian White |
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Hispanic? |
Yes No |
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If over age 12: Smoker? |
Current Every Day Current Some a Day Former Never |
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School Name If patient is a student, please list name of school. |
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School Status |
Full Time Part Time |
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Father's Information |
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Name |
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Address |
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City |
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State |
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Zip Code |
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Date of Birth |
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Age |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Employer |
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Employer Address |
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Home Phone |
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Cell Phone |
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Work Phone |
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Mother's Information |
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Name |
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Address |
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City |
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State |
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Zip Code |
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Date of Birth |
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Age |
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Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
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Employer |
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Employer Address |
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Home Phone |
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Cell Phone |
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Work Phone |
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Referring Physician |
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Physician's Name |
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Primary Care Physician (if different from Referring Physician) |
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Physician's Name |
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General Information |
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Emergency Contact Name |
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Date of Birth |
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Relationship to Patient |
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Address |
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City |
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State |
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Zip Code |
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Home Phone |
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Cell Phone |
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Work Phone |
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Can we leave appointment reminders? |
Yes No |
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If yes, preferred phone number? |
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Parent/Guardian E-mail address not required |
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Can we contact you via e-mail? |
Yes No |
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Primary Insurance Information Please provide us with your current insurance information and present your current insurance card(s). This helps ensure that we correctly bill your insurance for you. |
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Patient Insurance Information |
Health Insurance Claim Worker's Compensation Claim Auto Accident Claim None |
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Date of Injury (if applicable) |
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Name of Insurance Company |
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Insured's Name |
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Relationship to Patient |
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ID/Policy # |
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Group # |
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Effective Date |
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Insured's Employer |
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Employer's Phone Number |
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Employer Address |
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City |
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State |
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Zip Code |
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Insured's Date of Birth |
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Sex |
Male Female |
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Secondary Insurance Information |
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Name of Insurance Company |
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Insured's Name |
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Relationship to Patient |
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ID/Policy # |
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Group # |
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Effective Date |
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Insured's Employer |
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Employer's Phone Number |
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Employer Address |
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City |
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State |
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Zip Code |
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Insured's Date of Birth |
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Sex |
Male Female |
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