Get the free New Patient Registration Form: Adults

This form is used for the registration of new adult patients at Lane County Behavioral Health and Community Health Centers. It collects personal, contact, medical, and financial information, as well as consent for treatment and privacy practices acknowledgment.

How to fill out new patient registration form

How to fill out new patient registration form

1. Begin with personal information: Enter your full name, date of birth, and gender.
2. Provide contact details: Fill in your phone number, email address, and residential address.
3. Enter emergency contact information: Include the name and phone number of a person to contact in case of an emergency.
4. Fill out insurance information: Provide your insurance company's name, policy number, and policyholder’s details if applicable.
5. List medical history: Detail any past medical conditions, surgeries, and current medications.
6. Include family medical history: Note any relevant health issues in your immediate family.
7. Review and sign: Double-check all information for accuracy and sign to confirm everything is correct.

Who needs new patient registration form?

1. Anyone who is visiting a healthcare provider for the first time.
2. Patients who are switching to a new medical practice and require their information to be documented.
3. Individuals seeking treatment in a clinic or hospital that requires registration.

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What is new patient registration form?

A new patient registration form is a document used by healthcare providers to collect essential information about a new patient, including their personal details, medical history, and insurance information.

Who is required to file new patient registration form?

New patients seeking medical services are required to file a new patient registration form to ensure their information is accurately recorded in the healthcare system.

How to fill out new patient registration form?

To fill out the new patient registration form, provide accurate personal details such as name, address, and contact information, complete medical history questions, and include insurance information if applicable.

What is the purpose of new patient registration form?

The purpose of the new patient registration form is to gather necessary information to establish a medical record for the patient and facilitate appropriate care and billing.

What information must be reported on new patient registration form?

The form typically requires information such as the patient's name, date of birth, contact information, emergency contact, insurance details, and medical history.