PATIENT REGISTRATION FORM (eCW)
PATIENT INFORMATION
(Please print)
Patient’s Legal Name: (Last)___________________________________ (First)________________________________ (MI) __________
Preferred Full Name (if different from above): ________________________________
Home Phone Number (landline):__________________________ Cell:_________________________ Work: _______________________
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Email Address:____________________________________________________________________ Date of Birth: ___________________
Gender Identity:
Female Male Transgender Female to Male Transgender Male to Female Genderqueer
Choose not to disclose Additional Gender Category not listed ________________________________________
Race:
American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White
Hispanic Choose not to disclose Other not listed __________________________
Ethnicity:
Hispanic or Latino Not Hispanic or Latino Choose not to disclose
Preferred Language:
English Spanish ASL Japanese Mandarin Korean French Swahili Portuguese Arabic
Indian: Hindi, Tamil, Gujarati etc Russian Vietnamese Haitian Albanian Burmese Cambodian
Creole Bosnian/Croatian/Serbian/Serbo-Croatian Tagalog Farsi-Iranian/Persian Other not listed_____________
Patient Social Security Number:______-______-_______
RESPONSIBLE PARTY INFORMATION (If not self)
(Information used for patient balance statements)
Responsible Party:
Another Patient Guarantor Self Check here is address and telephone information is same as patient
Responsible Party Name: (Last)___________________________________ (First)________________________________ (MI) _______
Date of Birth: MM_____/ DD_____/ YYYY_________ Sex:
Female Male
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Responsible Party Social Security Number:______-______-_______ Phone Number:_____________________________
INSURANCE INFORMATION: Provide your insurance card(s) (primary, secondary, etc.) to the front desk at check-in.
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: (Last)_________________________________ (First)_____________________________________________
Phone Number:________________________________________________ Do you have a living will: Yes No
Emergency contact relationship to patient: _______________________________________________________________
Guardian
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Home Phone:______________________________________________ Work Phone:_______________________________ Ext.________
GENERAL CONSENT FOR CARE AND TREATMENT CONSENT
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to
be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.
At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the
evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are
indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you
consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.
You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have
any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician,
and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed
necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this
practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent
forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Signature of patient or personal representative:___________________________________________________Date:__________________
Printed name of patient or personal representative:__________________________________ Relationship to patient: _________________
Last Updated: May 2018
