Registration Form

Registration Form
Name: *

First Name Last Name
Social Security # (only required for Medicare coverage):
Date of Birth: *

Month Day Year
Date
Current Age: *
Sex: *
Gender: *
Preferred Pronouns: *
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Email: *
example@example.com
Preferred Method of Contact: *

Cell Home Work Email
Occupation:
Employer:
Physician:

First Name Last Name
Date of Last Exam:

Month Day Year
Date
Emergency Contact Information
Emergency Contact:

First Name Last Name
Phone Number:
Please enter a valid phone number.
Billing Information
Individual Responsible for Payment (if other than self):

First Name Last Name
Relationship:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Preferred Method of Contact:

Cell Home Work

AGREEMENT (Please read and sign below):

I understand that regardless of my health insurance status, I am ultimately responsible for payment of fees.

I agree to pay for any missed appointments with less than 24 hours’ advance notice.

I authorize the release of any information required to process my insurance claims.

I authorize health insurance payments directly to provider.
Client Signature:

Clear
Date:
Legal Guardian:

First Name Last Name
Legal Guardian Signature:

Clear
Date:

Month Day Year
Date
OFFICE USE (DO NOT FILL OUT)

Dx: ________________________________________________________________

Fee: ________________________________________________________________

Notes: ______________________________________________________________
Should be Empty: