PATIENT REGISTRATION FORM
Practice: [Practice name, address, phone, and website]
This form is for registration only. Your health history goes on the separate medical intake form. Write none or prefer not to say where a line doesn't apply.

ABOUT YOU
Legal name: [Last name, first name, and middle names, as on your ID and coverage card]
Name you use: [The first name you go by, if it's different]
Pronouns: [She, he, they, another, or prefer not to say]
Date of birth: [Date]
Sex assigned at birth: [Female, male, intersex, or prefer not to say]
Gender identity: [Woman, man, nonbinary, another identity, or prefer not to say]
Why we ask: The last two questions are optional. They help us call you by the right name and pronouns, and offer you the right screening tests.

CONTACT
Home address: [Street, unit, city, state or province, and postal or ZIP code]
Mailing address: [Same as home, or the address for letters]
Phones: [Mobile, and any home or work number]
Email: [Address]
Preferred contact method: [Phone call, text, email, patient portal, or mail]
Best time to reach you: [Days and times]
Voicemail: [Yes or no, which number, and whether anyone else uses that phone]
Text messages: [Yes or no: appointment reminders, portal notices, and any other messages you agree to]
Email messages: [Yes or no: reminders, forms, and notices that a result is ready]
I understand that texts and email are not fully private, and that anyone who uses my phone or inbox may see them. I can change these choices at any time.

LANGUAGE AND ACCESS
Preferred language: [For speaking, and for reading]
Interpreter needed: [Yes or no, and the language, including sign language]
Accessibility needs: [Wheelchair-accessible room, help with transfers, large print, hearing support, a support person, a service animal, extra time, someone to read forms aloud, or none]

EMERGENCY CONTACT
Name: [Full name]
Relationship: [Partner, parent, adult child, friend, or other]
Phone: [Mobile, and any other number]
What we may tell them: [That you're here and how you are, details of your care, or nothing without asking you]

NEXT OF KIN AND DECISION-MAKER
Next of kin: [Name, relationship, and phone, or same as the emergency contact]
Substitute decision-maker: [The person who decides about your care only if you can't, with their phone, or none named]
Legal document: [Power of attorney for health care, advance directive, guardianship order, or none; copy attached or to bring]
Who may discuss my care with the practice: [Names, relationships, and what each may do, such as book visits or hear results, or no one]

HEALTH COVERAGE
Coverage: [Public plan, private insurance, employer plan, workplace injury claim, self-pay, or other]
Plan or insurer: [Name]
Member number: [Member or policy number, and the group number if there is one]
Policy holder: [Self, or their name, date of birth, and relationship to you]
Second plan: [Insurer, member number, and policy holder, or none]
Coverage card: [Front and back copied or uploaded, or to bring to the first visit]
Responsible for payment: [Me, or a guarantor: name, relationship, address, and phone]
Billing address: [Same as home, or the address for statements]

PREVIOUS CARE
Previous clinician: [Name, practice, city, and phone]
Last seen: [Month and year]
Records: [Yes or no: I ask this practice to request my records from my previous clinician, and I have signed the release]
Records to request: [All, or the last few years, with test results, immunizations, and specialist letters]
Other clinicians I see: [Specialists, therapists, or others, with phone numbers, or none]
Pharmacy: [Name, address, and phone]

HOW YOU HEARD ABOUT US
Source: [Referred by a clinician, friend or family, online search, insurer's directory, or other]

ACKNOWLEDGMENTS
Privacy notice: [Received and read: yes or no, with the date]
Financial policy: [Read, including fees for services your coverage doesn't pay for]
Cancellation policy: [Read, including the notice needed to cancel and any fee for a missed visit]
Consent to treatment: [Yes or no: I consent to routine examination, tests, and treatment by the practice's clinicians. Before a procedure or new treatment, the clinician will explain it and ask me.]
Contact: [Yes or no: you may contact me in the ways I chose above]
Accuracy: I confirm this information is correct, and I'll tell the practice when it changes.

SIGNATURE
Patient: [Signature, printed name, and date]
Signed for the patient: [Name, relationship, legal authority, and why the patient isn't signing, or not applicable]
Help filling in the form: [Name and relationship of anyone who wrote or read the form for the patient, or none]

FOR OFFICE USE
Received: [Date, and online, paper, or in person; staff initials]
ID and coverage checked: [Yes or no, and the date]
Set up in the record: [Name used and pronouns on the schedule, contact choices, and interpreter, access, or large-print alerts]
Decision-maker and permissions: [Saved, with any document scanned, or none]
Records request: [Sent to, date sent, and follow-up date]
Medical intake form: [Sent, received, or to complete at the first visit]
Clinician and first visit: [Name, date, and length of the visit]