Patient Information Form | Regional Primary Care

Patient Information

First Name

Middle Name

Last Name

Phone Number

Type

Cell Work Home

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Marital Status

Social Security Number

Date of Birth

Sex

Race

Language

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown/Not Reported

Guarantor Information (Person Responsible for Payment)

First Name

Middle Initial

Last Name

Phone

Type

Home Cell Work

Address Line 1

Address Line 2

City

State

Zip Code

Relationship

Marital Status

Email

Social Security Number

Date of Birth

Sex

Emergency Contact

First Name

Middle Initial

Last Name

Address

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Relationship

Insurance

(Please Complete or attach copy of card - actual insurance card will be scanned at the time of visit)

What is the name of your insurance provider:

Medicare Medicaid BC/BS Other

Policy Effective Date

Name of Policy Holder

First Name

Middle Initial

Last Name

Relationship to Patient

Address of policy holder (if not the same as Patient's)

City

State

Zip Code

Phone Number

SSN of Policy Holder

Insurance ID Number

Group ID Number

Employment

Name of Employer

Occupation

Employer Phone

Address Line 1

Address Line 2

City

State

Zip

Advanced Directives

Date Reviewed :

Select an option

None DNR Living Will Durable Power of Attorney HC Proxy

Pharmacy

Preferred Retail Pharmacy

Phone Number

Address Line 1

Address Line 2

City

Zip

Preferred Mail-in Pharmacy

Phone Number

Address Line 1

Address Line 2

City

Zip