Free Patient Registration Form Template
Patient Registration Form
Please complete the form below to register as a new patient. Your responses will help us provide you with the best possible care. All information is confidential and will be used only for medical purposes.
I. Personal Information
Name
Sex
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Male
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Female
Date of Birth
Marital Status
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Single
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Married
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Divorced
-
Widowed
Height
Weight
Address
Phone number
II. Medical History
Do you have any existing medical conditions?
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Yes
-
No
If yes, please describe:
Are you currently taking any medications?
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Yes
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No
Do you have any allergies?
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Yes
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No
If yes, please specify:
III. Insurance Information
Insurance Provider
Policy Number
Group Number (if applicable)
IV. Emergency Contact Information
Name
Relationship
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Spouse
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Parent
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Child
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Sibling
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Guardian
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Phone number
Thank you for taking the time to complete this registration form.
