Patient Registration Form

Free Patient Registration Form

A patient registration form is a great way to retain a patients information in advance or before an appointment. It will get all the information you need to process their billing information and retain insurance information, if needed. The template is easy to use and can be downloaded for free. You can customize it to fit your needs and to get the required information that you need from the patient.

How to Use the Patient Registration Form

  • You will be able to edit or take out the items that you don’t need.
  • The first set of information, is going to be for the patient’s information. They will fill out their name, billing address information, birth date, social security number, sex, age, issue they are currently having, phone numbers, and much more!
  • You will also be able to have the patient put down their employment information to where they work, their occupation, and the phone number to the business they work for, under the patient information.
  • The following box is dedicated to insurance information. This is where they will put down their insurance name, address, phone number, group number, policy number, co-payment information, and much more. You can customize this part of the patient registration form to fit your needs, as well.
  • The last set of boxes that the patient will need to fill out will be for emergency contact information. They will just need to list the names and addresses of the individuals that would need to be contact in an emergency. They will also list how they are related to that person, and list their home and work phone numbers.
  • Finally, the patient will be able to sign and date the bottom of the patient registration form.


Tips on Using the Patient Registration Form

  • You can edit the form to fit your company needs and to get the accurate patient information that you need.
  • You can email the form to patients or have it available online. This way they can fill it out electronically.
  • If patients do not have access to the internet, you can print the form out to give them prior to the appointment.


Download: Patient Registration Form

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