FHCB Health System - Covid-19 Testing Patient Registration

Patient Registration Form

Please fill in the form below.
Patient Information
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Sex (At birth) *
Gender *
E-mail
Social Security Number:
Marital Status *
Race *
Ethnicity *
Are you a new patient? *
Please select from the available dates below to schedule your COVID-19 test: *
Contact Information
Contact Number: *

Area Code Phone Number
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Emergency Contact: *

First Name Last Name
Relationship *
Contact Number *

Area Code Phone Number
Guarantor Information

*Please complete if patient is 18 years old or has a legal guardian*
Parent(s)/Legal Guardian(s) Name(s):
Phone Number:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Information

If you do not possess insurance, please Type "N/A" into the required fields.
1. Medical Insurance: *
Member ID/Policy Number: *
Group Number: *
Subscriber's Name: *
Relationship to Patient: *
2. Other Insurance:
Member ID/Policy Number:
Group Number:
Subscriber's Name:
Relationship to Patient:

Patient Registration Form