Get New Patient Demographic.docx

This guide provides a comprehensive overview of how to complete the New Patient Demographic.docx form online. By following these steps, you will ensure that all necessary information is provided accurately and efficiently.

Follow the steps to complete the New Patient Demographic form effectively.

1. Click the ‘Get Form’ button to access the New Patient Demographic.docx and open it in your preferred editor.
2. Begin filling out the Patient Information section. Provide your full name, address (including street, city, state, and zip code), and contact numbers (cell phone, home, and work). Enter your date of birth, social security number, email address, and select your sex. Choose your marital status and race from the provided options.
3. Indicate your preferred language and ethnicity. If you are married, fill in your spouse’s name, date of birth, and phone number.
4. List your emergency contact details, including their name, date of birth, relationship to you, and contact number.
5. Provide the name and contact information of your primary care physician and referring physician, if applicable. This includes their names, addresses, and phone numbers.
6. Complete the Employment section. Provide your employer's name, your occupation, employer address, and their phone number.
7. If applicable, indicate the person responsible for the bill, along with their date of birth, address, phone number, and relationship to you.
8. Fill out the Insurance Information section, including details for primary and secondary insurance plans, policy numbers, group numbers, and policy holder information.
9. Read and sign the Release of Medical Records and Assignment of Benefits section, acknowledging your understanding and agreement.
10. Fill in the Payment Policy section based on your insurance status and understand your responsibilities as stated.
11. Complete the Preferred Pharmacy Selection by providing the names, addresses, and phone numbers of your preferred pharmacies.
12. Sign the Consent to Obtain Medication History, allowing the practice to collect necessary medication information.
13. Acknowledge the Notice of Privacy Practices by signing the appropriate section.
14. If applicable, complete the Photography and Video Consents section, indicating whether you consent to the use of your images.
15. Finally, review all sections for accuracy. Save any changes, and you can choose to download, print, or share the completed form as needed.

Complete your forms online today for a smooth registration process.