Registration Form Name Social Security No.: Address City State Zip

Registration Form
Name
Social Security No.:
Address
City
Sex M/F Age
State
Birth date
Zip Code
Marital Status
Phone
S/M/W/D/SEP
Patient Employed By:
Occupation:
Business Address:
Business Phone No.:
Whom may we thank for referring you?
In case of emergency who should we contact?
Phone No.:
Primary Insurance (Card Holder)
Person responsible for the account
Relationship to patient:
Birth date:
Social Security No.:
Address if different from patient:
City
State
Zip code
Person responsible employed by
Occupation
Business Address
Business Phone No.:
Phone
Insurance
Policy No.:
Group No.:
Name of other dependents covered under this plan:
Assignment and Release
I hereby authorize mediCenter to furnish information to insurance carriers concerning my illness/injury and treatment. I hereby
assign mediCenter all payments for medical services rendered to myself or my dependent. I understand that I am responsible for any
amount not covered by my insurance company.
Parental consent is given to mediCenter to treat my children and dependents.
I have read mediCenter’s “Notice of Privacy Practices”
Signature of Insured/Guardian
Date