Patient Registration Form

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Patient Registration

Reliance Family Care & Locust Grove Family Medicine

Please complete the following form and submit for the patient you are registering with our practice. It will be necessary to complete this form for each person you are registering. If you have questions about the online pre-registration process, please contact our office.

Additional personal information, such as your Social Security Number may be requested when you come into our offices. Please fill this form out as completely as you can so that we can start your file and contact you for an appointment. If there is information you do not want to share online, then please contact us by phone to make an appointment. If you are registering a child, make sure you put the child's information under general patient, and your information under the extended information.

*Denotes required field
GENERAL PATIENT INFORMATION

First Name, Middle Initial:	*
Email Address:
Last Name:	*
Physician Preferred:	*
Date of Birth:	* mm/dd/yyyy
CONTACT INFORMATION

Address:	*
City:	*
Zip Code:	*
Home Phone:	* (xxx)xxx-xxxx
Work Phone:
Email:	*
Date of Birth:	* mm/dd/yyyy
Extended Information (Parents Information - If this is for a person under 18)

Full Name :
Address:
Home Phone #:	(xxx)xxx-xxxx
Work Phone #:	(xxx)xxx-xxxx
Date of Birth:	mm/dd/yyyy
Employer:
Relationship:
How did you hear about us?
INSURANCE INFORMATION

Primary Insurance:
Policyholder Full Name:
Effective Date	mm/dd/yyyy
Policy #:
Group #:
Employer:

Which office would you like to register?