CHANGE IN PATIENT INFORMATION

Patient Registration Form
Which Henry Fertility office location will you be visiting?*

Methodist Medical Plaza North (Carmel, IN)Professional Office Building, AP&S Clinic,(Terre Haute)Lafayette Women’s ClinicAegis Women’s Clinic (Bloomington)Southern IN Physicians for Women (Bloomington)
What Day of the Week is your appointment?
Appointment Date

MonthDayYear
Date
Appointment Time:

Hour Minutes

AM/PM Option

PATIENT INFORMATION: **FEMALE PATIENT ONLY**
Name

First NameLast Name
Middle Initial:*
Please provide the patient middle initial
Maiden Name:*
E Mail Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Do you accept text messages on your cell phone?*

YESNO
Date of Birth:*

MonthDayYear
Date
Age*
SS#
Ethnicity *
Marital Status*

PHYSICIAN INFORMATION
Primary Care Physician
Address
City
State
Zip Code
Phone
Referring M.D.
Address
City
State
Zip Code
Phone
How did you learn about our medical practice?*

EMPLOYMENT INFORMATION
Employer
Business Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Occupation
May we contact you at work?
Please answer "YES" or "NO"
If yes, what hours are best

SPOUSE OR SIGNIFICANT OTHER INFORMATION
What is your Spouse or Significant Other's gender?*

MaleFemaleOther
If other, please provide details
Name (of your spouse or significant Other)*
Date of Birth*

MonthDayYear
Spouse or Significant Other
Social Security Number
Spouse or Significant Other
Cell Phone*
Employer
Business Phone
Occupation
Spouse Business Address

Address

Street Address Line 2

CityState

Zip

INSURANCE INFORMATION
Member ID#
Group#
Phone
(Please provide the phone number of your insurance provider)
Who is the insurance provided through?

SpousePatientSignificant OtherParentOther
Please list social security number and date of birth of person who carries your on insurance if not already listed above:
Social Security #
(Of person who carries your insurance)
Date of Birth

MonthDayYear
(Of the person who carries your insurance)

Patient Registration Form
IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)
Name*
Relationship*
Cell Phone*
Address*
CONTACT INFORMATION:

Our preferred method of contact is by email.
WHAT IS YOUR PREFERRED METHOD OF CONTACT?*

Emailhome phonecell phone
May we also contact you via text messaging?*

YESNO
Cell Phone Number to receive text messages
Consent to Treat: I request and give consent to my physician to provide and perform such medical/surgical care, tests, procedures, drugs and other services and supplies as considered necessary or beneficial by my physician for my health and well being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me.
Initial*
Please provide your initials to authorize Consent to Treat.
Assignment and Release: I authorize my physician to release information from my medical record to my insurance carrier(s), or government agency for the processing of claims for medical benefits. I request that my insurance company(s) honor my assignment of insurance benefits applicable to the services and pay all assigned insurance benefits directly to my physician, on my behalf.
Initial*
Please provide your initials to authorize Assignment and Release.
Financial Agreement: I understand the fees for all services rendered are the full responsibility of the patient. It is the patient's responsibility to make sure insurance payments are processed and paid promptly to my physician. In the case of default payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts.
Initial*
Please provide you initials to authorize Financial Agreement.
I understand the above and fully understand the terms thereof:
I understand the above and fully understand the terms thereof: SIGNATURE OF PATIENT OR RESPONSIBLE PARTY*

Clear
DATE*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Patient Registration Form

PHYSICIAN INFORMATION

EMPLOYMENT INFORMATION

SPOUSE OR SIGNIFICANT OTHER INFORMATION

INSURANCE INFORMATION

Patient Registration Form

IN CASE OF EMERGENCY CONTACT: (OTHER THAN SPOUSE)