Patient Registration Form

PATIENT REGISTRATION FORM
Patient Name*
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Marital Status*

SingleMarriedDivorcedWidowedSeparated
Address*
City, State, Zip*
Appointment confirmations are via text and email unless the OPT-OUT form is completed.
Preferred Phone Number*
Please enter a valid phone number.
Type*

CELLLANDLINEWORK
Alternate Phone Number
Type

CELLLANDLINEWORK
Social Security*
(Required for Insurance)
Email Address
Primary Language*

EnglishSpanishOther
Ethnicity*

Hispanic / LatinoNOT Hispanic LatinoDecline to Specify
Race*

American Indian / Alaska NativeAsianBlack / African AmericanHawaiian / Pacific IslanderWhiteDecline to Specify / Unknown
Employer
Who can we thank for referring you to our practice?

Family / FriendPatientPhysician ReferralWebsiteADInsurance
Family / PCP Physician:
Name
Address
City, State, Zip
Phone
DATE LAST SEEN

MonthDayYear
Pharmacy:
Name*
Address
City, State, Zip*
Phone
Emergency Contact:
Name
Relationship to Patient
Phone
CELLLANDLINEWORK
Advance Care Directive
An Advance Care Directive is a legal document that provides instructions for medical care and only goes into effect if you cannot communicate your own wishes.
Do you have an Advance Care Directive?

NoYes
Name of Custodian of document
Relationship to Patient
Phone
CELLLANDLINEWORK
INSURANCE INFORMATION

*** Insurance Card(s) and photo ID must be given to front desk at time of service ***
Primary Insurance
Insurance*
Referral Required?*

NoYes
Policy / ID #*
Group #*
Insured / Subscriber*
Relationship to Patient*
Social Security #*
Date of Birth*

MonthDayYear
Insured Employer*
Secondary Insurance
Do you have a secondary insurance?*

YesNo
Insurance*
Referral Required?*

NoYes
Policy / ID #*
Group #*
Insured / Subscriber*
Relationship to Patient*
Social Security #*
Date of Birth*

MonthDayYear
Insured Employer*
Will this treatment be done because of?
Workers Compensation Injury?

NoYes
Date of Injury

MonthDayYear
Do you have a first report of injury?

NoYes
Physician of Record
WC Claim #
Managed Care Organization
Claims Representative
Phone #
Auto / Personal Accident?

NoYes
Date of Injury

MonthDayYear
Claim #
Auto / Homeowners Insurance
Claims Representative
Phone #
I, the undersigned, certify that I (or my dependent) have provided Complete Foot & Ankle Specialists, LLC with all my correct insurance information and certify coverage with my insurance as presented and assign directly to Complete Foot and Ankle Specialists, LLC all insurance benefits, payable to me for services rendered. I understand that I am responsible for payment of deductibles, co-payments, and/or non - covered services and other fees AT THE TIME OF SERVICE. I understand that it is my responsibility to inform Complete Foot and Ankle Specialist, LLC if there is a change in my health insurance information.

I understand all appointment confirmations are via text and email. I further understand I may be contacted at my preferred phone number, via text, email, patient portal and/or mail regarding appointment, medical, and billing information. If I would like to change these communication settings, I understand I need to complete an OPT-OUT form.
Signature*

Clear
(If the patient is a minor, the legal guardian must sign)
Date*

MonthDayYear
Q
K
Bundle
Should be Empty:

PATIENT REGISTRATION FORM

Family / PCP Physician:

Pharmacy:

Emergency Contact:

Advance Care Directive

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

Will this treatment be done because of?