PATIENT REGISTRATION FORM
COMPLETION OF THIS FORM IN ITS ENTIRETY IS REQUIRED AT TIME OF VISIT.
Susan Schmitt, M.D., GCFP
/
Month
/
Day
Year
Today's Date
Patient Name
*
First
Middle
Last
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
Cell Phone
Mailling Address
Mailing Address if different than street address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth date
*
/
Month
/
Day
Year
Age
Driver's License
minor
Sex
Please Select
Male
Female
N/A
Patient Pronouns:
He/Him/His
She/Her/Hers
They/Them/Theirs
Decline to answer
Marital Status:
Please Select
Married
Single
Divorced
Widowed
Partnered
Employed by
Occupation
Work Phone
Spouse’s Name
Employed by
Cell/Home Phone
Nearest Friend or Relative (Not Living With Patient)
Relationship to Patient
Work Phone
Referred By
Primary Care Physician
Phone
Email Address
example@example.com
IF PATIENT IS A MINOR, PLEASE INDICATE WHO IS RESPONSIBLE FOR THE BILL AFTER INSURANCE PAYS
Name of Responsible Party
Address
Phone
Employed by
Work Phone
ALLERGIES (Please list ALL allergies)
1.
2.
3.
Please Indicate Type if any:
*
No Insurance Coverage
Health Insurance
Work Injury
Auto Injury
Other
OK to leave a detailed message
Name of Primary Health Insurance Company
Name of Insured
Name of Insured
Birth Date of Subscriber / Insured
/
Month
/
Day
Year
Date
Address
Phone Number
Group Number
ID Number
Secondary Insurance
Name of Secondary Health Insurance Company
Address
Phone Number
Name of Insured
Subscriber/Insured Birth Date
/
Month
/
Day
Year
Group Number
ID Number
WORK INJURY OR AUTO INJURY CLAIM INFORMATION:
/
Month
/
Day
Year
Date of Injury
Claim Number
Name of Insurance Company
Address
Phone Number
Employer at Time of Accident
Accepted Condition
Claim Rep/Adjuster's Name
Attorney (Name, Address, Phone Number)
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