Patient Registration Form

Save time in the waiting room. Submit your patient registration information before your appointment by filling out this form. Your information will be emailed to the office manager.

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
(###)### - ####
Work Phone*
(###)### - ####
Mobile Phone
(###)### - ####
Email
Date of Birth*
Month
Day
Year

mm/dd/yyyy
Age*
Please enter a number from 0 to 200.
Sex*
- Male
- Female
Marital Status*
Race/Ethnicity*
EMPLOYMENT INFORMATION
Employment Status*
Employer Name*
Occupation*
INSURANCE INFORMATION
Optional if you are over 18 and the main policyholder on the plan.
Name of Insurance Carrier
Policy Number
Group Number
Name of Policyholder
Policyholder's Date of Birth
Month
Day
Year

mm/dd/yyyy
Relationship to Policyholder
Policyholder's Employer
Employer Phone
(###)### - ####
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
FOR MINORS
Responsible Party
Relationship
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone
(###)### - ####
EMERGENCY CONTACT / NEXT OF KIN
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Relationship to Patient*
AUTHORIZATION AND VERIFICATION
Initial Here to Authorize Disclosure*

I authorize LeBauer HealthCare to release medical information that may be necessary to request reimbursement by my insurance company to whom I have submitted claims. I understand I am responsible for all medical fees during my treatment with LeBauer HealthCare. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medical, private insurance, and other health plans to: LeBauer HealthCare.
Date
Month
Day
Year
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Patient Registration Form

EMPLOYMENT INFORMATION

INSURANCE INFORMATION

FOR MINORS

EMERGENCY CONTACT / NEXT OF KIN

AUTHORIZATION AND VERIFICATION

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