Families First Annual Patient Registration

Emergency Contact Information

(In an emergent situation, the person listed below may be made aware that you are receiving care at our facility)
Contact Name: *

First Name Last Name
Contact Relationship *
Contact Phone Number: *
Okay to speak with regarding your appointments? *

Yes No
Okay to speak with regarding your medical care? *

Yes No
Preferred Local Hospital *

Insurance Information and Patient Preference
Do you have insurance? *
Coverage may require notifying carrier of your PCP. This is the responsibility of the patient. Failure to do so may result in patient being billed directly for services provided. Please acknowledge this notification: *

I acknowledge that the patient/guardian is responsible for notifying the insurance carrier of current Provider AND that if notification is not provided, patient/guardian will be financially responsible for service charges
Primary Insurance Name:
Policy Number:
Group Number:
Subscriber's Name: *
Subscriber's Date of Birth: *

Month Day Year
Date
Subscriber's Relationship to Patient:
Secondary/Dental Insurance Name:
Policy Number:
Group Number:
Subscriber's Name:
Subscriber's Date of Birth:

Month Day Year
Date
Subscriber's Relationship to Patient:
Employer providing insurance coverage:
If you have a scanned image of your insurance card, please upload it here:

Upload a File
Front and back sides of the card Cancel of
How did you hear about us?
Patient / Guardian Electronic Signature: *

Clear
Patient Name: *

First Name Last Name
Today's Date *

Month Day Year
Date

Name (First MI Last)

Sex

Relationship to you

Date of Birth

Income ($) and Frequency

Income Type

First Household Member

Second Household Member

Third Household Member

Fourth Household Member

Fifth Household Member

The above information supplied is current and accurate to the best of my knowledge. Should inaccurate information be provided, any discount given will be reversed based on this information.
If you have a scanned image of your proof of income, please upload it here:

Upload a File
Front and back sides of the card Cancel of
Patient/Guardian Signature *

Clear

Patient Annual Registration Form