New Patient Registration — Minors

Fill this out before your visit. Review the completed form, then sign and send.

Authorization for medical treatment

Appoint adults (18+) who may consent to medical treatment for your child if you cannot be reached.

Caregiver 1 — name & relationship to child

Caregiver 1 — phone

Caregiver 1 — address

Caregiver 2 — name & relationship to child

Caregiver 2 — phone

Caregiver 2 — address

Caregiver 3 — name & relationship to child

Caregiver 3 — phone

Caregiver 3 — address

Caregiver 4 — name & relationship to child

Caregiver 4 — phone

Caregiver 4 — address

Parent / legal guardian 1 — name

Parent / guardian 1 is the

Parent / guardian 1 — address

Parent / guardian 1 — phone

Parent / legal guardian 2 — name

Parent / guardian 2 is the

Parent / guardian 2 — address

Parent / guardian 2 — phone

Signature

Date

Applied automatically.

Patient information

Please print clearly. Your name and date of birth carry to every page.

Full legal name

Date of birth

Social Security number

Home address

Apt #

City

State

ZIP

Home phone

Cell phone

Work phone

Preferred phone

Email address

Gender

Marital status

Race / ethnicity

Preferred language

Parent / guardian (if patient is under 18)

Mother's name

Mother's phone

Father's name

Father's phone

Guardian's name

Guardian's phone

Employment

Student

Other status

Employer / school

Employer / school address

City / state

ZIP

Employer / school phone

Financially responsible party

Complete only if someone other than the patient is financially responsible.

Is the patient the responsible party?

Insurance

Primary insurance company

Subscriber's name

Subscriber's SSN

Subscriber's DOB

Patient's relationship to insured

Policy #

Group #

Secondary insurance company

Subscriber's name

Subscriber's SSN

Subscriber's DOB

Patient's relationship to insured

Policy #

Group #

Do you have a Living Will?

Do you have a Power of Attorney for Healthcare?

Returning patients only

Skip if you are a new patient.

No changes to my information

I confirm there are no changes to my demographic and insurance information.

Consent & signature

I have read and understand the information above and consent by signing below.

Signature

Date

Applied automatically.

Patient Policy acknowledgment

My signature indicates I have read and understood the T&R Clinic Patient Policy.

This form is completed by

Signature

Date

Applied automatically.

Immunizations & screenings — year of last

Tetanus / Td

Influenza (flu)

Pneumonia

Hepatitis

Rectal / stool

Cholesterol

Eye exam

T.B. test

Hospital admissions (not including pregnancies)

Admission 1 — year

Admission 1 — illness or operation

Admission 6 — year

Admission 6 — illness or operation

Admission 2 — year

Admission 2 — illness or operation

Admission 7 — year

Admission 7 — illness or operation

Admission 3 — year

Admission 3 — illness or operation

Admission 8 — year

Admission 8 — illness or operation

Admission 4 — year

Admission 4 — illness or operation

Admission 9 — year

Admission 9 — illness or operation

Admission 5 — year

Admission 5 — illness or operation

Admission 10 — year

Admission 10 — illness or operation

Medications & allergies

List all medications you now take, including over-the-counter.

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Allergy 1

Allergy 2

Allergy 3

Allergy 4

Allergy 5

Allergy 6

Social history

Alcohol (oz per week)

Smoking (cigarettes per day)

Years smoked

Year quit

Coffee / tea (cups per day)

Women's health

For female patients.

Advance directives & risk factors

Do you have an advance directive?

Patient Portal consent

Opt in to use the secure patient portal, or opt out.

Patient portal

Signature

Date

Applied automatically.

Privacy — who we may speak to

List people we may share your medical information with.

Primary contact name

Relationship

Address

City / state

ZIP

Phone

Alternate phone

Emergency contact 1 name

Relationship

Address

City / state

ZIP

Phone

Alternate phone

Emergency contact 2 name

Relationship

Address

City / state

ZIP

Phone

Alternate phone

Initials — I acknowledge receipt of the Privacy Practice

Initials — I authorize appointment confirmation to my employer/school

May we leave confidential messages (e.g. reminders) on your voicemail?

Initials

Guardian / parent name (if applicable)

Signature

Date

Applied automatically.

New Patient Registration — Minors

Registration received