Registration Form


Note: Pressing the TAB key after completing filling in a text field will move the cursor to the next field.

Patient Information
Patient Name	*	Sex	Male Female
Address	*	Marital Status	Single Married Divorced Widowed
City/State/Zip Code	*	Date of Birth	*
Home Phone #	*	Social Security #
School		Primary Care Provider	*
		Emergency Phone #	*
		Emergency Name	*
		Relationship	*




Personal Insurance Information
Primary Insurance Co	*	Secondary Insurance Co
Group #		Group #
Identification #	*	Identification #
Co-Pay		Co_Pay
Subscriber Name	*	Subscriber Name
Address	*	Address
City/State/Zip Code	*	City/State/Zip Code
Home Phone #	*	Home Phone #
Relationship to Patient	*	Relationship to Patient
Date of Birth	*	Date of Birth
Social Security #		Social Security #
Employer	*	Employer




AUTHORIZATION FOR TREATMENT, BENEFITS AND RELEASE OF MEDICAL RECORDS TO:
Employer Insurance Company Primary Care Physician Referring Physician
Physical Therapy DME Supplier Attorney Name of Attorney

I understand and agree, regardless of my insurance status, I am ultimately responsible for the balance of my account and my dependent's account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information.

* Required Field