The Shappley Clinic
Patient Registration Form
Date: _______________ (Please Print & Complete in Full)
MRN#: _____________ Physician’s Name: _____________________
PATIENT INFORMATION
Social Security #: ____________-____________-_____________
Last Name: __________________________ First Name: __________________________ MI: _____
Address: ___________________________________________________________________________
City: __________________________ State: ___________ Zip: __________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Date of Birth: _____/_____/_____ Age: _____ Sex: Male Female
Marital Status: Single Married Widowed Divorced Separated
Race: African American Asian Caucasian Hispanic Native American Other
If Patient is a child, lives with: Both Parents Mother Father Other: ___________
Name of Person (With Whom Child Lives With): ____________________________________________
RESPONSIBLE PARTY IF OTHER THAN PATIENT
Social Security #: ____________-____________-_____________
Responsible Party Name: ________________________________________________________________
Address: ___________________________________________________________________________
City: __________________________ State: ___________ Zip: __________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Date of Birth: _____/_____/_____ Sex: Male Female Relationship: __________________
Responsible Party Employer: ___________________________________________________________
PATIENT EMPLOYER INFORMATION
Employed: Yes No Student: Full-Time Part-Time
Name: _________________________________ Address: __________________________________
City: __________________________ State: ___________ Zip: __________
Main Office Phone: (_______)________-__________ Occupation: __________________________
INSURANCE INFORMATION (We require a copy of your card)
Primary Insurance: __________________________________ Copay: Yes No Amount: $______
Policy Holder Name: _________________________________ Relationship: ____________________
Date of Birth: _____/_____/_____ Percentage Plan Pay (example 80%): _________________________
Insurance Address: ___________________________________ Phone:(_______)________-__________
City: __________________________ State: ___________ Zip: __________
If Insurance is through an Employee, please give Employer name: _______________________________
Policy Number: ______________________________ Group Number: _______________________
SECONDARY INSURANCE INFORMATION (We require a copy of your card)
Primary Insurance: __________________________________ Copay: Yes No Amount: $______
Policy Holder Name: _________________________________ Relationship: ____________________
Date of Birth: _____/_____/_____ Percentage Plan Pay (example 80%): _________________________
Insurance Address: ___________________________________ Phone:(_______)________-__________
City: __________________________ State: ___________ Zip: __________
If Insurance is through an Employee, please give Employer name: _______________________________
Policy Number: ______________________________ Group Number: _______________________
REFERRED BY:
Referring Physician: _________________________________ Phone:(_______)________-__________
If not referred by a physician, how did you hear about our office:
Web Page Yellow Pages Friend/Family Radio Insurance Directory
TV Emergency Room Newspaper Other: ________________________
PRIMARY CARE PHYSICIAN NAME (if different from above)
PCP Physician: ______________________________________ Phone:(_______)________-__________
IN CASE OF EMERGENCY
Relative/Friend: ________________________________________________________________________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Relationship: _____________________________
EMERGENCY CONTACT (that does not live in your Household):
Name: _____________________________________________________________________________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Relationship: _____________________________
PHARMACY INFORMATION
Pharmacy Name: _____________________________________________________________________
Phone Number: (_______)________-__________ Fax Number: (_______)________-__________
(If Known)
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to
the physician. I understand that I am financially responsible for any balance. I also authorize Middle Tennessee
Urology Specialist or insurance company to release any information required to process my claims.
PATIENT SIGNATURE: ____________________________________ DATE: ___________________
