Patient Registration Form – Access Medical Center

ACCESS MEDICAL CENTER PATIENT REGISTRATION

Patient Full Name:

□ New Patient □ Existing Patient

Reason for Visit:

Date of Birth: ________________________________________                  Gender: □ Male □ Female

Social Security #: _____________________________________ Ethnicity/Race:_________________

Local Address:_______________________________________  Apt #:_________________________

City:_________________________ State:_________________  Zip:___________________________

Primary Phone #:_____________________________________                 □ Home □ Cell □ Work

Secondary Phone # :__________________________________                  □ Home □ Cell □ Work

Email Address:_______________________________________
By providing your email address, you consent to our Email Privacy Policy

How did you hear about us? □ Location □ Customer Service □ Email □ Facility Signage □ Family/Friend/Word of Mouth □ Internet/Online Search □ Print Advertising □ Radio □ Phone Book/Yellow Pages

□ School/Daycare: ___________________                                             □ Employer: ___________________ □ Community Event: _________________                                              □ Hotel: ______________________ □ Physician Referral: _________________                                              □ Pharmacy: ___________________ □ Apartment Complex: _______________                                               □ Insurance: ___________________

Marital Status: □ Child □ Single □ Married □ Divorced □ Widowed □ Separated

Spouse’s Full Name:__________________________________
Permanent Address (other than local):___________________________________
City:________________________ State:______________________  Zip:_________________
Primary Care Physician:_________________________________________________________ Employer:________________________________________________

Insurance Subscriber Information (Complete Only if Not the Patient)

Insured Subscriber Full Name:_______________________________________
Subscriber’s Date of Birth:__________________________________________
Subscriber’s Social Security #:_______________________________________
Subscriber’s Relationship to Patient:__________________________________
Subscriber’s Permanent Address:________________________________  Apt #:_________________ City:_____________________  State:_____________________  Zip:_______________________ Subscriber’s Primary Phone #:_____________________________________ □ Home □ Cell □ Work Subscriber’s Secondary Phone #:___________________________________ □ Home □ Cell □ Work Subscriber’s Employer:___________________________________________
Complete Insurance Details:

Insurance Company:_____________________________________________
Type:       □ HMO / PPO            □ Medicare              □ Medicaid/AHCCCS           □ Tricare               □ Other
ID / Policy #:________________________________  Group #:_______________________________ Copay/Coins/Ded Amount:_________________________ Effective Date:______________________ Secondary Insurance? □ Yes □ No   Name:_______________________________________________

Parent/Legal Guardian of Minor or Incapacitated Adult Only:

Full Name:__________________________  Date of Birth:________________________
Relationship:________________________  Contact #:___________________________

Signature:

Patients Name:_________________________  Date:____________________________

Signature:_______________________________________________________________

 

Thank you for choosing Access Medical Center. Your satisfaction is important to us! Please leave your email address in the space provided and we will send you a survey about your visit today.f