COVID-19 Patient Registration

Please do not complete this form if you have not made an appointment with us already to be tested
Registration Form
Patient Information
Patient's last name:*
First:*
Is this your legal name?

YesNo
If not, what is your legal name?
Date of birth*

MonthDayYear
Date
Sex:*

MF
Phone no.:*
Street address:*
City:*
State:*
ZIP Code:*
Occupation:
Employer:
Employer phone no.:
Insurance Information
Subscriber's name:
Birth date:

MonthDayYear
Date
Relationship to Insured

SelfSpouseChildOther
Name of Primary Insurance:*
Policy Number
Name of secondary insurance (if applicable):
Policy Number:
In Case of Emergency
Name:
Relationship to patient:
Home phone no.:
Work phone no.:
ASSIGNMENT AND RELEASE:

·         I hereby assign my insurance benefits to be paid directly to the physician

·         I understand that I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I authorize and give consent for my provider to bill me directly for recommended services performed that are not covered or not exempted under the terms of my health plan.

·         I authorize the physician to release any medical information required to process this claim.
CONSENT TO TREAT

·         I authorize my provider’s office to conduct telehealth visits when necessary.

·         I authorize New Path Medical Center to identify and carry out the appropriate treatment and/or procedure for any identified condition(s).

·         I understand I have the right to refuse any procedure or treatment

·         I understand I have the right to discuss all medical treatments with my clinician.

·         I authorize New Path Medical Center to perform any laboratory testing deemed clinically necessary.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize New Path Medical Center or insurance company to release any information required to process my claims.
Patient/Guardian signature*

Clear
Date*

MonthDayYear
Date
Patient History
Today's Date:

MonthDayYear
Date
Name:
DOB:
Past Medical History: Please check all that apply to you

ArthritisPsychiatric diseaseCancerHeart problemsStrokeDepressionEpilepsy/seizuresHeart surgeryHigh blood pressureThyroidDiabetesNoneOther
Previous Surgeries:
Current Medications and Dosage
Preferred Pharmacy
City
Allergies: please list any allergies you have:
Do you smoke?

YesNo
If yes, how many cigarettes/day?
Family History: Please list any relevant medical history of any blood relatives
Do you currently have any of the following symptoms? (Check all that apply)

WeaknessFatigueNasal dischargeNasal infectionsCoughShort of breathCoughingRunny noseAbdominal painVomitingDiarrheaNausea
Please upload a photo of a valid Photo ID
Please upload a photo of your insurance card
Should be Empty:

Registration Form

Patient Information

Insurance Information

In Case of Emergency

Patient History