Patient Registration Form
(PLEASE PRINT FORM, THEN FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT. THANK YOU)
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NAME_________________________________________________________________________ ______/____/_________
(LAST) (FIRST) (INITIAL) (DATE OF BIRTH)
ADDRESS___________________________________________________________________________________________
(STREET) (CITY) (ST) (ZIP)
HOME PHONE ( ) __________ - _______________ CELL PHONE ( ) _________ - ______________
****PLEASE INDICATE WHICH NUMBER YOU PREFER TO BE CALLED ON___________________________________
SSN ________ - _____ - ____________ SEX M / F MARTIAL STATUS _______________________
REFERRED BY _______________________________________________________
EMPLOYER ______________________________________ WORK PHONE ( ) __________ - ______________
EMPLOYER ADDRESS________________________________________________________________________________
(STREET) (CITY) (ST) (ZIP
EMERGENCY CONTACT _____________________________________________________________________________
(NAME) (PHONE)
SPOUSE’S NAME______________________________________________________ _______/_____/____________
(LAST) (FIRST) (INITIAL) (DATE OF BIRTH)
EMPLOYERS___________________________________________ WORK PHONE ( ) __________ - ____________
(COMPLETE BELOW IF PATIENT IS CHILD)
SCHOOL ___________________________________________________ GRADE________________________
SIBLINGS_____________________________________________ _________________
(NAME) (AGE)
______________________________________________ __________________
(NAME) ( AGE)
FATHER’S NAME_______________________________________________________ _____/____/___________
(LAST) (FIRST) (INITIAL) (DATE OF BIRTH)
ADDRESS ____________________________________________________________________________________
(IF DIFFERENT THAN ABOVE)
EMPLOYER_____________________________________________ WORK PHONE ( ) _______ - __________
MOTHER’S NAME ______________________________________________________ _____/____/___________
(LAST) (FIRST) (INITIAL) (DATE OF BIRTH)
ADDRESS ___________________________________________________________________________________
(IF DIFFERENT THAN ABOVE)
EMPLOYER_____________________________________________ WORK PHONE ( ) _______ - _________
PATIENT INSURANCE INFORMATION
BLUE CROSS INFORMATION ONLY
SUBSCRIBER __________________________________________ _____/___/__________
(Last) (First) (Date of Birth)
CONTRACT NUMBER _______________________________________________________
GROUP NUMBER________________________ EFFECTIVE DATE _________________
PATIENT’S RELATIONSHIP TO SUBSCRIBER SELF/SPOUSE/DEPENDANT
OTHER INSURANCE COMPANY’S AND OR SECONDARY INSURANCE
INSURANCE COMPANY NAME_________________________________________________
ADDRESS____________________________________________________________________
TELEPHONE NUMBER ________________________ WEBSITE______________________
SUBSCRIBER ________________________________________________________________
DATE OF BIRTH ______/____/_______ SSN _______ - _____ - ___________
POLICY/ID NUMBER _____________________________ GROUP ___________________
IF WORKMAN’S COMPENSATION OR AUTOMOBILE CLAIM
INSURANCE COMPANY/EMPLOYER NAME_____________________________________
INSURANCE ADDRESS________________________________________________________
PHONE NUMBER__________________ DATE OF INJURY/ACCIDENT ____/___/_____
CLAIM NUMBER_______________________ POLICY NUMBER_____________________
I agree to be financially responsible for all services rendered to the above listed individual(s). I understand that services are to be paid at the time of each session unless otherwise arranged with Dr. Carol Van Dyke.
____________________________________________________ _______________________
Signature Date
I hereby authorize direct payments of any and all medical benefits to Dr. Van Dyke for services rendered.
____________________________________________________ _______________________
Signature Date