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\\Hera\access\Forms\Patient_Registration.DOC
FHPC OFFICE USE ONLY
Last: ________________________ First __________________________ Middle _____________________
Total in Family ______ Total Income _________ % _____ Info entered by: _______ Med Rec. No.__________
PATIENT REGISTRATION
Date: _______________________
Patient Name: ____________________________________________ Date of Birth __________________
Social Security Number _____________________________________ Male ____ Female ____
Address __________________________________________________________ City _________________
State ____ Zip ____________ Home Phone ___________________ Cell Phone ______________________
PARENT/GUARDIAN INFORMATION (IF UNDER 18)
Name ______________________________________ Relationship to patient ________________________
Address __________________________________________________________ City _________________
State ____ Zip ____________ Home Phone ___________________ Cell Phone ______________________
EMERGENCY INFORMATION
In case of emergency, who should we notify: ___________________________________________________
Relationship to you: ____________________________Phone Number to contact: _____________________
ADDITIONAL INFORMATION
How did you hear of our clinic? _____________________________________________________________
Are any of your other family members patients here? If so, who? __________________________________
I HEREBY CERTIFY THAT THE INFORMATION ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE
________________________ ___________________ _____________ Signature Date Witness