681 Medical Center Drive West #106    Clovis, CA 93611
Phone: (559) 325-6850   Fax: (559) 325-6853
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Patient Registration Form OP Version 8


Only complete this form if you are NOT currently a patient.

This is a "secure" form. To ensure the privacy of your personal information, all data provided on this form is encrypted for transmission between your computer and our web server.
For your convenience, all children who share the same parent(s) or legal guardian(s) and are covered by the same insurance plan can be entered at the same time. If these factors are not the same for any of your children, you must submit a separate form for them.
Please Note: This form is designed for pre-registration of a new family to our practice, it currently can not be used to add a new family member. If your family is already registered with our practice please register any new family members directly with the office, NOT online.
In cases of divorce and/or remarriage, please provide information for the adult(s) who have legal custody (the authority to make medical decisions on the child's behalf), with the person who most often has physical custody listed first. You will have an opportunity to provide contact information for other interested adults, such as step-parents, when you visit the office.

Parent/Guardian Information

   
Parent/guardian 1 (most frequent contact for healthcare issues)
Relationship:    should always be checked
Name (first, MI, last):    
Address:  
City/state/zip code:
Home phone:
Work phone: Ext:
Cell phone:
Home Email Addr:
Work Email Addr:
Preferred method of communication.
Medical: Reminder: Recall: Billing:
Parent/guardian 2 (leave address/phone blank if same as above)
Relationship:   
Name (first, MI, last):
Address:
City/state/zip code:
Home phone:
Work phone: Ext:
Cell phone:
Home Email Addr:
Work Email Addr:
Preferred method of communication.
Medical: Reminder: Recall: Billing:
Insurance information
Insurance company:

 

Group number:
Provided through
parent/guardian:		   1                           2                           Other
Patient (child) information
If you are expecting a child, please enter "BABY" as the first name, along with an approximate due date.
       
First name MI Last name Sex Birth/due date Insurance ID

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