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University Eye Specialists, LTD 676 North St. Clair, Suite 1500 Chicago, IL 60611 P: (312)475-1000 1535 Lake Cook Rd., Suite 305 Northbrook, IL 60062 P: (847)562-4330 NEW PATIENT REGISTRATION FORM

How to fill out new patient registration form

How to fill out a new patient registration form:

1. Start by writing your personal information. This typically includes your full name, date of birth, gender, address, phone number, and email address.
2. Next, provide your insurance information. This may include your insurance company's name, policy number, and group number.
3. Fill out any medical history sections. This typically requires you to provide details about your past and current medical conditions, medications you are currently taking, any allergies or sensitivities you have, and any surgeries or hospitalizations you have undergone.
4. Complete the emergency contact section. Here, you should provide the name, phone number, and relationship of the person to be contacted in case of an emergency.
5. If applicable, provide your primary care physician's information. Include their name, phone number, and address.
6. Consider signing any necessary consent forms. This may include giving permission to release your medical records or allowing the clinic to bill your insurance company.
7. Review your form for accuracy and completeness. Double-check that all the information you have provided is correct and legible.

Who needs a new patient registration form?

1. New patients: Anyone who is visiting a healthcare provider for the first time will typically need to fill out a new patient registration form.
2. Existing patients with updated information: Even if you are an existing patient, you may need to fill out a new patient registration form if there have been any changes to your personal or medical information since your last visit.
3. Patients switching healthcare providers: If you are transferring your care to a new healthcare provider, you will likely need to fill out a new patient registration form to provide them with your updated information.

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What is new patient registration form?

The new patient registration form is a document that collects information about a patient who is seeking medical care for the first time at a healthcare facility.

Who is required to file new patient registration form?

Any new patient seeking medical care at a healthcare facility is required to file a new patient registration form.

How to fill out new patient registration form?

To fill out a new patient registration form, the patient needs to provide personal information such as name, address, contact details, insurance information, medical history, and any other relevant information requested by the healthcare facility.

What is the purpose of new patient registration form?

The purpose of the new patient registration form is to gather essential information about the patient to provide proper medical care, create a patient record, and ensure accurate billing and insurance processing.

What information must be reported on new patient registration form?

The information required on a new patient registration form typically includes but is not limited to personal details, emergency contacts, insurance information, medical history, current medications, and any allergies or medical conditions.