Patient Registration Form

Please fill our our safe and secure online form. Additionally, you may download and print the form by clicking here.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Mobile Phone

Language *

Date of Birth *

Social Security # *

Marital Status *

Primary Care Physician

Employer

Emergency Contact

Emergency Phone Number

Pharmacy Name

Pharmacy Address & Phone

PERSON RESPONSIBLE FOR PAYMENT IF PATIENT IS UNDERAGE 18

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Date of Birth

Social Security #

Employer Name

Employer Phone Number

PRIMARY INSURANCE

Primary Insurance Name

Primary Insurance Address

Address Line 1

Address Line 2

City

State

Zip Code

Subscriber Name *

First

Last

Date of Birth

Sex

Subscriber ID #

Group #

Relation to Patient *

Secondary Insurance

Secondary Insurance Name

Secondary Insurance Address

Address Line 1

Address Line 2

City

State

Zip Code

Subscriber Name *

First

Last

Date of Birth

Subscriber ID #

Group #

I understand and accept that I will be financially responsible for all deductibles, co-payments, co-insurances, and non-covered charges as provided by my insurance plan. If my insurance plan requires a valid referral to receive medical care. I understand that it is my responsibility to provide such referral. If my referral is determined to be invalid by my insurance carrier, I understand that I will be financially responsible for balances on my account including non-covered items. If my insurance plan is not accepted by this office or is of the indemnity type I understand that I am financially responsible for all balances remaining after payment, if any, made by my insurance plan. I hereby authorize and assign directly to Surgical Health Collective all medical benefits, if any, otherwise payable to me for services rendered. I hereby authorize the physician and/or their representative(s) to re-lease any and all information necessary to secure the payments of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. *

I agree
I DO NOT agree

Initials *

Date

Name

PERSON RESPONSIBLE FOR PAYMENT IF PATIENT IS UNDERAGE 18

PRIMARY INSURANCE

Secondary Insurance

SHC provides quality surgical care with an excellent staff. We provide outpatient services through our clinic.

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