PATIENT REGISTRATION FORM (eCW)
PATIENT INFORMATION (Please print)
Patient’s Legal Name: (Last) (First) (MI)
Preferred Full Name (if different from above): ________________________________
Address:
City, State, Zip:
Home Phone Number (landline):______ ______Cell: _________Work:
E-Mail 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
Chose 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 Indian: Hindi, Tamil, Gujarati etc
Swahili Russian Arabic Vietnamese Haitian Creole Bosnian/Croatian/Serbian/Serbo-Croatian
Albanian Burmese Tagalog Farsi-Iranian/Persian Portuguese Cambodian 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 if address and telephone information is same as patient
Responsible party name: (Last) (First) (MI)
Date of birth: MM /DD /YYYY
Sex:
Female
Male
Responsible Party Social Security Number: - - Phone number:
Address:
City, State: ZIP:
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 hone: 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
