Identity New Patient Registration

Patient Name Used (if different)
Identity New Patient Registration
Today's Date*

MonthDayYear
Date
How did you hear about us
Name*

Patient Legal First NamePatient Legal Last Name
Patient Name Used (if different from Legal Name)
Pronouns*
Patient Date of Birth*

MonthDayYear
Patient Date Of Birth - DO NOT PUT TODAYS DATE
Patient Social Security Number*
Patient Driver's License Number*
Home phone number
Cell phone number*
Work phone number
Patient Email*
example@example.com
Preferred Contact
Patient Mailing Address*
City*
State*
Zip*
Patient Primary Language
Patient Race (optional)
Patient Ethnicity
Patient Legal Gender*
Patient Assigned Gender at Birth*
Patient Gender Identity*
Patient Sexual Orientation
Patient Marital Status
Employer
Employer Phone Number
Reason for Seeking Care:
Some options may be: Gender Affirming Care, STI Care, PreP, Primary Care, Medication Management
Emergency Contact Information (Required by Law)
Emergency Contact Name*
Emergency Contact Number*
Emergency Contact Relationship to Patient*
For those under 18 or Legal Guardian

If you are over 18 or do not have a legal guardian please skip to the next section
Name

Guardian First NameGuardian Last Name
Guardian Name Used (if different from Legal)
Guardian Date of Birth

MonthDayYear
Date
Guardian Mailing Address - Include City, State and Zip
Guardian Email
example@example.com
Preferred Phone
Guardian Social Security Number
Insurance Information
Primary Insurance Name*
Primary Insurance ID Number*
Primary Insurance Group Number
Primary Insurance Start Date

MonthDayYear
Date
Subscribers Name*
Subscribers Date of Birth*

MonthDayYear
Date
Subscribers Address

Subscribers Address

Street Address Line 2

CityState

Zip
Subscribers Relationship to Patient*
VA/TriCare Only: Social Security Number of Member
Secondary Insurance Name
Secondary Insurance ID Number
Secondary Insurance Group Number
Secondary Insurance Start Date

MonthDayYear
Date
Subscribers Name
Subscribers Date of Birth

MonthDayYear
Date
Secondary Subscribers Address

Subscribers Address

Street Address Line 2

CityState

Zip
Subscribers Relationship to Patient
VA/TriCare Only: Social Security Number of Member
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Identity Health Clinic and/or insurance companies to release any information required to process my claims.
Patient/Guardian signature*

Clear
Date*

MonthDayYear
Date
My preferred pharmacy is
My preferred Emergency Room is
My preferred imaging facility is
My preferred lab is (Identity Health Clinic utilizes Quest Lab, or we can send your orders elsewhere, we also do some labs in house)
Should be Empty:

Identity New Patient Registration

Emergency Contact Information (Required by Law)

For those under 18 or Legal Guardian

Insurance Information