PATIENT REGISTRATION FORM

Date:*

First Name*

Middle

Last Name*

Preferred Name: What you prefer to be called

Birth Date*

Gender*

MaleFemale

Last 4 SS#:

Address*

Address Street/Apt#

Street Address Line 2

CityState

Zip

Email*

Primary Care Physician

Phones: Home

Cell

Work

Emergency Contact

Name

Relationship

Phone

Preferred Pharmacy Name

Preferred Pharmacy Phone

Who referred you? / Where did you hear about us?

Are you a minor?

YesNo

Father/Guardian

Name

Street Address Line 2

Phone

Mother/Guardian

Name

Street Address Line 2

Phone

Other family members seen in office

Employer

Occupation

Work Address

Street Address

Street Address Line 2

CityState

Zip Code

Will you be using insurance?

YesNo

Are you the primary insurance holder?

YesNo

Primary Insurance Co.

Primary Insured's Name

Insured's Birth Date

Insured's Relationship to Patient:

SpouseFatherMotherOther

Second Insurance Co.

Insured's Name

Insured's Birth Date

Insured's Relationship to Patient:

SpouseFatherMotherOther

Lawrence Osman MD, PC will use your medical information for the following: TREATMENT: Including providing your medical records to consulting clinicians and insurance companies. PAYMENT: Insurance companies may request part or all of your medical records to pay the claim. HEALTH CARE OPERATIONS: Any others involved in your healthcare. The Private Policy Notices of Lawrence Osman MD, PC is posted in the waiting room for your perusal. If you would like to obtain a copy, please ask the front office, and we will gladly provide one.

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I certify this information is true and correct. I will notify you of any change in the status of the above information.

Date

Signature of Patient or Parent if a Minor*