New Patient Registration (Form 1 of 3)
Please complete this DEMOGRAPHIC INFORMATION to register as a new patient at Family Care, PA. Required fields are marked with a Red Asterisk. After you submit this form, you will be transferred to a second form to complete your Health History information. This is the 1ST OF 3 times you will complete a form, sign your name, and hit Submit before you will have completed your New Patient Registration.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Patient's Cell Phone Number
*
###-###-####. Please enter a landline, if you do not have a cell phone.
Patient's Email Address
*
Email you would like to use for our Patient Portal.
Patient's Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the Patient's GENDER?
Please Select
Agender
Androgyne
Demigender
Genderqueer, or Gender Fluid
Man
Questioning, or Unsure
Trans-Man
Trans-Woman
Woman
Additional
Prefer Not to Disclose
What is the Patient's SEXUAL ORIENTATION? You may select more than one.
Asexual
Bisexual
Gay
Straight / Heterosexual
Lesbian
Pansexual
Queer
Questioning / Unsure
Identity Not Listed
Prefer Not to Disclose
What is the Patient's MARITAL STATUS? You may only select one.
Single
Married
Divorced
Separated
Other
What is the Patient's ETHNICITY?
*
What is the Patient's SPEAKING LANGUAGE? You may select more than one.
*
English
Spanish
Other
What is the Patient's EMPLOYMENT STATUS? You may select more than one.
Employed, Part-Time
Employed, Full-Time
Student, Part-Time
Student, Full-Time
Disabled, Temporary
Disabled, Permanent
Unemployed
Retired
Other
Patient's Emergency Contact
First Name
Last Name
Patient's Emergency Contact Phone
###-###-####
Patient's Relationship to Emergency Contact
*
eg. Parent, Brother/Sister, Friend, Spouse, etc.
Which PHARMACY would you like to use as your default pharmacy?
*
What is your selected PHARMACY'S PHONE NUMBER?
*
###-###-####
Which HEALTH INSURANCE PROVIDER covers the Patient's medical services?
*
Blue Cross Blue Shield
Cigna
United Healthcare
Aetna
Medicare
Uninsured
Other
What is the Patient's SUBSCRIBER ID NUMBER?
*
You may skip this, if you are able to provide a photo copy of your insurance card below.
Upload a photo (.jpg, .gif, or .pdf) of the FRONT AND BACK OF THE PATIENT'S INSURANCE CARD. You will need to provide this before your appointment.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If completing this form for someone else, what is YOUR NAME?
First Name
Last Name
What is YOUR RELATIONSHIP to the Patient?
*
I am the Patient.
My child is the Patient.
My parent is the Patient.
My friend is the Patient.
Other
I, the undersigned, certify that the information provided on this form is accurate and truthful. If I intend to claim insurance benefits for services rendered at Family Care, I certify that the insurance coverage I have provided is accurate and truthful. In exchange for providing and billing these services to my insurer, I assign directly to Family Care, PA all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I, the Responsible Party named below, am financially responsible for all charges that have been duly processed through my insurance and still assigned to patient responsibility. I hereby authorize the doctor to release all information necessary to secure payment of my benefits. I authorize the use of this signature on all insurance submissions and claims for medical services provided by Family Care.
Please verify that you are a human being.
*
Submit
Should be Empty: