Patient Registration
(For Office Use Only)

Admission Date______________     Account # _________________

 Clinician______________________      Dx Code___________________
_____________________________________________________________

PATIENT INFORMATION
Patient Name Last________________________ First_____________________________ M.I_______

Address_______________________________ City____________________________Zip___________

Phone #____________________________ Sex:_______  Age:____________________ DOB___/___/__

Employer/School Attending______________________________ Ph #____________________________

Address_________________________ _____________Occupation/School Grade___________________

Referred By________________________________ If Minor Who Has Custody_____________________

Emergency Contact_____________________________ Relation_________________________________

Address______________________________________Ph#______________________________________

Responsible/ Insured Party

Name:________________________ ______________Relation_________________________________

Address:__________________ City:________________________    ST/ Zip:   ____________________

Phone (HM)_______________________ (WK)____________________ Cell______________________

Employer____________________________________ Occupation______________________________

Employer Address ____________________________________________________________________

Insurance Information

Insurance Co__________________________________________ Ph #____________________________
Address______________________________________________________________________________
Policy Holder_____________________________________________ Soc Sec #____________________
DOB__________________________ Contract#_______________________ Group #________________

Benefit Verification
Deductible $__________________ Met( ) Yes( ) no Copay $__________________ Yr Max____________

____________________________________________________________________________________
Patient/Responsible Party Signature   Date                Witness                                   Date