PATIENT NAME (FIRST, MIDDLE INITIAL, LAST, NICKNAME IF ANY)
DATE OF BIRTH
STREET ADDRESS
CITY, STATE, ZIP CODE
SOCIAL SECURITY NUMBER
MAILING ADDRESS IF DIFFERENT THAN ABOVE
HOME PHONE
SEX
 Male  Female
EMAIL ADDRESS
ETHNICITY
 HISPANIC OR LATINO
 NOT HISPANIC OR LATINO
 UNKNOWN
EMERGENCY CONTACT NAME
DAYTIME/WORK PHONE
CELL PHONE
MARITAL STATUS
 Single  Married Other______________
WOULD YOU LIKE TO BE REGISTERED FOR THE PATIENT PORTAL, WHICH ALLOWS YOU
TO COMMUNICATE WITH US ELECTRONICALLY?
 YES
NO
 I AM ALREADY REGISTERED
RACE
PREFERRED LANGUAGE
 ASIAN
 ENGLISH
 BLACK OR AFRICAN AMERICAN
 SPANISH
 WHITE
Other____________________________________
 NATIVE HAWAIIAN OR OTHER PACIFIC
 OTHER
EMERGENCY CONTACT PHONE NUMBER(S)
RELATIONSHIP
PRIMARY CARE PHYSICIAN NAME (PLEASE PROVIDE CONTACT INFORMATION IF HE/SHE DOESN’T PRACTICE LOCALLY)
ARE THERE ANY OTHER DOCTORS INVOLVED IN YOUR CARE WHO YOU WOULD LIKE TO RECEIVE COPIES OF YOUR RECORDS WITH US?
(PLEASE PROVIDE CONTACT INFORMATION IF THEY DO NOT PRACTICE LOCALLY)
INSURANCE INFORMATION-PLEASE PRESENT YOUR CARDS UPON CHECK-IN
PRIMARY INSURANCE COMPANY
COMPANY NAME __________________________________________
INSURANCE ID NUMBER _____________________________________
ARE YOU THE PRIMARY SUBSCRIBER?
 YES
 NO-PLEASE PROVIDE THE PRIMARY SUBSCRIBER’S NAME, DATE OF BIRTH AND RELATIONSHIP TO THE PATIENT
__________________________________
SECONDARY INSURANCE
COMPANY NAME __________________________________________
INSURANCE ID NUMBER _____________________________________
ARE YOU THE PRIMARY SUBSCRIBER?
 YES
 NO-PLEASE PROVIDE THE PRIMARY SUBSCRIBER’S NAME, DATE OF BIRTH AND RELATIONSHIP TO THE
PATIENT___________________________________
DO YOU HAVE ANY OTHER INSURANCE? IF YES, PLEASE LIST THE INFORMATION HERE
DO YOU MAKE MEDICAL AND FINANCIAL DECISIONS FOR YOURSELF?
 YES
 NO-PLEASE PROVIDE YOUR LEGAL REPRESENTATIVE’S NAME, ADDRESS, PHONE NUMBER AND RELATIONSHIP __________________________________
SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE
DATE