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Patient Registration Form
Patient's Name (Last, First
, MI): ____________________________________________________________
Patient's Home Phone Number: _____________________ Alternate Phone Number ( cell or work): __________________________
E-Mail Address:
Address: ___________
_______________________________________________ Apt. # ____________
City: ________________________________ State: _________________ Zip: ________________
Date of Birth: ____________________ Age: ______ Sex: M F
Social Security Number: ___________________________
Marital Status: [ ] Married [ ] Single [ ] Divorced [
] Widowed
Patient’s Employer: _____________________
_______ Employment Status: [ ] Full time [ ] Part time [ ] Unemployed
[ ] Retired [ ] Student [ ] Other: __________________
INSURANCE INFORMATION
Primary Insurance: ____________________
Patient is Subscriber/Policy Holder: Y N
Secondary Insurance: _________________
___
Patient is Subscriber/Policy Holder: Y N
INSURED INFORMATION (IF OTHER TH
AN PATIENT) - We will request to scan your ID and insurance card
Subscriber/ Policy Holder: _________________________________________ Relationship to Patient: ________________________
Address: _____________________________________________________________________________________________________
Social
Security Number: _________________________________
Date of Birth: __________________________________________
His or Her Employ
er: ____________________________________ Work Phone Number: _________________________________
RELEASE OF INFORMATION
I hereby give permission t
o the person(s) listed below to receive information about the care of the above named patient.
Name(s): ______________________________________
________ Relationship to Patient: __________________________________
Inova Medical Group reserves t
he right to charge a fee for any scheduled visits that are:
1. Cancelled with less than 24 hours notice
2. Are missed without calling to cancel ( no show)
Cancellation Fee schedule: New Pa
tient $50.00; Established Patient: $35.00
Patient / Parent or Guardia
n Signature: __________________________________________________ Date: ____________________
___________________________________________
®
Emergency
Contact: ___________________________________________
Relationship to Patient: ____________________________
Address: _____________________________________________________
Phone number: ________________________
®