PATIENT
REGISTRATION FORM Affix Label
PATIENT INFORMATION
______________________________________________________ _____________________ Sex: Male Female
Full Legal Name (First, Middle, Last, Suffix) Nickname:
________________ ___________________________ ___________________ ______________________
Date of Birth Social Security Number Race Preferred Language
Ethnicity: Hispanic Non-Hispanic Marital Status: Single Married Separated Divorced Widowed Life Partner
____________________________________________________________________________________________________
Complete Mailing Address (Street, City, State, Zip Code, County)
Home Phone Number: ________________ Cell Phone Number: _______________ Work Number: __________________
Email: __________________________________________________
Employment Status: Full-time Part-time Active Duty Self-employed Not employed Retirement Date: _______
Employer Name: __________________________________________ Employer Phone Number: ____________________
____________________________________________________________________________________________________
Employer Complete Address (Street Address, City, State, Zip Code)
SPOUSE OR GUARANTOR INFORMATION (Responsible Party) Same as Patient
______________________________________________________ ______________ ____________________
Full Legal Name (First, Middle, Last, Suffix) Date of Birth Social Security Number
Relation to Patient: Self Spouse Mother Father Legal Guardian Other: ______________ Sex: Male Female
Thank you for
Home Phone Number: ________________ choosing
Cell Piedmont Fayette Hospital
Phone Number:______________ Work Number: ___________________
____________________________________________________________________________________________________
Complete Mailing Address – If Different From Patient (Street, City, State, Zip Code, County)
Employment Status: Full-time Part-time Active Duty Self-employed Not employed Retirement Date: _______
Employer Name: _________________________________________ Employer Phone Number: _____________________
____________________________________________________________________________________________________
Employer Complete Address (Street Address, City, State, Zip Code)
EMERGENCY CONTACT INFORMATION
Name (First, Last):____________________________________________________________________________________
Relation to Patient: Spouse Mother Father Legal Guardian Other: ____________
Home Phone Number: ________________ Cell Phone Number:_______________ Work Number: __________________
____________________________________________________________________________________________________
Complete Mailing Address – If Different From Patient
INSURANCE INFORMATION Self-pay (no insurance)
Primary Insurance: ________________________ Patient relation to subscriber: Self Spouse Child Other: _______
Secondary Insurance: ______________________ Patient relation to subscriber: Self Spouse Child Other: _______
Prescription/Rx Provider: _______________________________________________ (if different from insurance carrier)
Full Name of subscriber: _______________________ (complete below if different from patient, spouse, or guarantor)
Employment Status: Full-time Part-time Active Duty Self-employed Not employed Retirement Date: _______
Employer Name: ___________________________________________ Employer Size: 0-19 employees 20-99 100+
____________________________________________________________________________________________________
Employer Complete Address (Street Address, City, State, Zip Code)
Primary Care Physician: Do you want anyone to know you are here? Yes or No
Epic registration form 08/12
