New Patient Registration (Form 1 of 3)

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 NameLast Name
Patient's Date of Birth

MonthDayYear
Patient's Cell Phone Number
###-###-####. Please enter a landline, if you do not have a cell phone.Format: (000) 000-0000.
Patient's Email Address
Email you would like to use for our Patient Portal.
Patient's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the Patient's GENDER?
What is the Patient's SEXUAL ORIENTATION? You may select more than one.
What is the Patient's MARITAL STATUS? You may only select one.

Other
What is the Patient's ETHNICITY?
What is the Patient's SPEAKING LANGUAGE? You may select more than one.

Other
What is the Patient's EMPLOYMENT STATUS? You may select more than one.

Other
Patient's Emergency Contact

First NameLast Name
Patient's Emergency Contact Phone
###-###-####Format: (000) 000-0000.
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?
###-###-####Format: (000) 000-0000.
Which HEALTH INSURANCE PROVIDER covers the Patient's medical services?

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.

Cancelof
If completing this form for someone else, what is YOUR NAME?

First NameLast Name
What is YOUR RELATIONSHIP to 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.
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