New Patient Registration Form

Date

Reason for Visit

How did you hear about us?

PATIENT INFORMATION

Date of Birth

Sex at Birth

Preferred First Name

Gender

Non-binary

Street Address

Street Address City State ZIP Code

Cellphone

PARENT/LEGAL GUARDIAN INFORMATION

Legal Name

First Last

Relationship to Patient

Street Address (if different from patient)

Street Address City State ZIP Code

Phone

Alternate Phone

DISCLOSURE OF PERSONAL HEALTH INFORMATION

Additional adults authorized to receive health information pertaining to patient:

Legal Name

First Last

Relationship to Patient

Phone

IN THE CASE OF A MINOR PATIENT

Patient resides with

Relationship to Patient

** If there are documents to prove medical decision-making authority or legal custody, please bring copies to your appointment to scan into the electronic medical record. **

INSURANCE INFORMATION

Primary Insurance

Policy Number

Group Number

Policy Holder Name

First Last

Date of Birth

Policy Holder's Address (if different from above)

Street Address City State ZIP Code

PREFERRED PHARMACY

Name

Phone

City

State

Zip

CERTIFICATION OF INFORMATION

I hereby certify that the above information is true, correct, and complete in all respects.

Signature of Person Completing this Form

Printed Name

Relationship to Patient

Date

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

PATIENT INFORMATION

PARENT/LEGAL GUARDIAN INFORMATION

DISCLOSURE OF PERSONAL HEALTH INFORMATION

IN THE CASE OF A MINOR PATIENT

INSURANCE INFORMATION

PREFERRED PHARMACY

CERTIFICATION OF INFORMATION

Our Locations

Hours