\\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