Patient Registration Information * Required FieldDate of scheduled appointment* MM slash DD slash YYYY Practitioner Name* First Last PATIENT INFORMATIONPatient Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Home Phone*Home Phone*Birth Date* MM slash DD slash YYYY Social Security - Last 4 digits*Gender*What is your reason for seeking therapy at this time?*CONTACT PREFERENCESPlease Choose your Preferred Contact Method: Cell Phone Home Phone Email If it is not your preferred method, may we reach you at home if needed? Yes No MARITAL AND FAMILY INFORMATIONMarital Status*SingleMarriedDivorcedWidowedDomestic PartnershipOtherSpouse/Partner Name if applicableSpouse/Partner Date of Birth MM slash DD slash YYYY Is Patient a Child?* Yes No Name: Parent 1*Name: Parent 2Were you referred to this practice? Yes No Referred By*Referred by Contact Method:* Phone Email Referred by PhoneReferred by Email May I thank your referral source?* Yes No PRIMARY CAREPrimary Care Provider*Primary Care Provider Contact* Phone Email Primary Care Provider Phone*Primary Care Email* EMPLOYMENTEmployment* Full Time Part Time Not Employed Patient employed by:Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Phone*Student* Yes No Status* Full Time Part Time School Attending*PAYMENTResponsible Party for Payment* Patient Other Relationship to Patient*Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEMERGENCY CONTACT PERSON(S)Contact 1* First Last Phone*Relationship*Contact 2 First Last PhoneRelationshipPRIMARY INSURANCE COMPANYInsurance Company*Subscriber Name* First Last Subscriber Date of Birth* MM slash DD slash YYYY Policy ID*Group ID*SECONDARY INSURANCE COMPANYSecondary Insurance* Yes No Secondary Insurance Company*Subscriber Name* First Last Signature*Subscriber Date of Birth* MM slash DD slash YYYY Policy ID*Group ID*I have read and received a copy of the office HIPAA privacy notice.* Yes I consent to treatment by the above named practitioner* Yes Date* MM slash DD slash YYYY Signature*Responsible Party Signature
