PATIENTRE
P
EGISTRATIO
ONFORM
GENE
ERALINFORM
MATION
LastN
Name:__________________________________________ FirstName:__________________________________________ MiddleInittial:____________
DateofBirth:________________________________________ MaritalS
Status: Si ngle
AmericanIn

dian/AlaskaN
Native
*Racee: Assian
NativeHawa

aiianorOtherPacificIslander
W
White

DomesticPaartner
 Married

Black/AfricaanAmerican
*Ethn
nicity:
HispanicorL

Latino
N
Non‐HispanicorLatino
*Religion:____________________________________________
*Requ
uiredbyHealthcare/Meaningfu
ulUseLegislation
PrimaryLanguage:
English
S
Spanish
Other,pleaasespecify:________________________________________________
Addrress:______________________________________________________________________________________________________ Apt#:_____________________
City:________________________________________ Staate:__________ Zip:______________________ C
Country:_____________________________________
HomePhone:______________________________ CellPhone:________________________________ A
AlternatePhon
ne:____________________________
PrefeerredPhone:
Hom
me
C
Cell Alt
Email:____________________________________________________________________
Mayw
weleaveameessageregardiingyourcare(results,appo
ointments,etc..)onyourpreferredphone??  Yes No
EMER
RGENCYCON
NTACTINFOR
RMATION
ContaactName:___________________________________________________________________ Phone:___
_______________________________
_________________
RelattionshiptoPattient:___________________________________________________________________________________________________________________
REFE
ERRALINFOR
RMATION
Howdidyouhearaboutus?
ReferringgPhysician
Family/F
Friends
Website(ccolumbiaobgyyn.org) Internett
Other,pleaasespecify:_________________________________________________
ReferrringPhysicianName:___________________________________________________
_____________________________________________________________
Phon
ne:__________________________________________________________________ Fax: _____________________________________________________________
Doyo
ouwantavisitreportsentttoyourreferriingphysician??
Yees No
PrimaryCarePhyssicianName(ifotherthanR
RefMD):__________________________________________________________________________________
Phon
ne:__________________________________________________________________ Fax: _____________________________________________________________
EMPL
LOYMENTIN
NFORMATION
N
EmplloymentStatu
us:
Uneemployed Studeent
SeelfEmployed
Employed
 Retired
Occupation:__________________________________________________ EmployerNaame:________________________________________________________
PHAR
RMACYINFORMATION
PrefeerredPharmaccyName:______________________________________________________________ P
Phone:_____________________________________ Addrress:_________________________________________________________________________________________________________________________________
City:________________________________________ Staate:__________ Zip:______________________ C
Country:_____________________________________
GUAR
RANTOR(PerrsonResponsiibleforBill)
GuarantorName:_______________
_
____________________ Gender: M ale Femalee
Dateo
ofBirth:______________________
Addrress:______________________________________________________________________________________________________ Apt#:_____________________
City:________________________________________ Staate:__________ Zip:______________________ C
Country:_____________________________________
Phon
ne:_____________________________________ Em
mail:_________________________
_____________________________________________________________
INSU
URANCEINFORMATION
PrimaryInsuranceeCompanyNaame:____________________________________________________ P
Phone:_______________________________________
Policy/ID/Memberr#:___________________________________________________________ Group#:________________
________________________________
PolicyHolderNam
me:___________________________________________________RelattionshiptoPaatient: Selff Spouse//Partner
DateofBirth:___________________________________________________________ SociaalSecurity#:_______________________________________________
Secon
ndaryInsuran
nceCompanyN
Name:__________________________________________________ P
Phone:_______________________________________
Policy/ID/Memberr#:___________________________________________________________ Group#:________________
________________________________
PolicyHolderNam
me:___________________________________________________RelattionshiptoPaatient: Selff Spouse//Partner
DateofBirth:___________________________________________________________ SociaalSecurity#:_______________________________________________
Icerttifythatthea
aboveinforma
ationisaccurrateandup‐to
o‐datetothe bestofmykn
nowledge,and
dIunderstan
ndthatIam
finan
nciallyrespon
nsibleforchargesincludin
ngco‐insurance,deductiblees,copaymen
ntsandserviccesnotcovereedbymy
insurrance.
Patieent(orRespon
nsibleParty):_______________
_
____________________________________________________Date:________________________________