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Patient Registration Form

Basic Information

Name
Sex
MM slash DD slash YYYY
Primary Phone

Demographics

Hispanic or Latino?

Emergency Contact

Name
Primary Phone
Address

Financial Information

Responsible Party
Who will be financially responsible for you?
If you chose “Someone Else”, please fill out the following:
Name
Primary Phone

Method of Payment

What will be your method of payment?
If you chose “Insurance”, please fill out the following:
PRIMARY INSURANCE POLICY
Address
If you are not the primary policy holder, please fill out the following:
Full Name
Sex
MM slash DD slash YYYY
Address
If you are unable to provide your insurance information, please provide a reason before continuing.
SECONDARY INSURANCE POLICY
If you do not have a secondary insurance policy, you can leave this blank.
Address
If you are not the primary policy holder, please fill out the following:
Full Name
Sex
MM slash DD slash YYYY
Address

Additional Information

Please list your preferred pharmacies in order of preference