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3142 Horizon Road, Suite 201 Rockwell, Texas 75032 Phone: 469-757-4410 Fax: 469-277-3911 NEW PATIENT REGISTRATION FORM Please Print Personal Information Today s Date: / / Name (First, Middle, Last):

How to fill out new patient registration form

How to fill out a new patient registration form:

1. Start by providing your personal information such as your full name, date of birth, and contact details.
2. Next, fill in your medical history including any allergies, current medications, and past surgeries or hospitalizations.
3. You may be required to provide your health insurance information, so be sure to have your insurance card handy.
4. If you have a primary care physician or any preferred specialist, mention their details on the form.
5. Some registration forms may ask for emergency contact information, so include the name and phone number of a trusted contact.
6. Read through the privacy policy and sign the consent form if required.
7. Finally, check for any additional fields, such as your preferred pharmacy or any specific medical conditions you have, and complete them accordingly.

Who needs a new patient registration form?

1. Any individual who is new to a healthcare facility or provider will likely need to fill out a new patient registration form.
2. It is essential for individuals seeking medical care for the first time or those switching their healthcare provider.
3. Hospitals, clinics, and doctor's offices typically require new patients to fill out a registration form to gather necessary information for medical treatment and record-keeping purposes.
4. It ensures that healthcare providers have accurate and up-to-date information about the patient, which helps in delivering appropriate care.

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