Patient Sticker Here

Ambulatory Registration PATIENT DEMOGRAPHIC INFORMATION Legal Name

Date of Birth

Address

City

County of Residence Preferred Language of Communication: Gender:

M

F

State

Country English

Zip

SSN

Spanish

Other

Marital Status

Race:

American Indian or Alaska Native White Multiracial

Ethnicity:

Hispanic or Latino

Phone

Asian Unknown

Black or African American Declined

Not Hispanic or Latino

Declined

Alternate Phone

Preferred Method of Communication:

Email

Native Hawaiian or other Pacific Islander Unknown

Email Address Mail

Home Phone

Primary Care Doctor

Cell Phone

Work Phone

Declined

Referring Doctor

Employment Status (Circle One) Full-time

Part-time

Disabled

Retired

Not Employed

Employer Name

Self Employed

On Active Duty

Employer Phone

Retirement Date (if applicable) Is visit due to accident? Accident:

If yes, Accident Type

Date

Time

Location

PATIENT GUARANTOR INFORMATION (Complete if other than patient) Patient Relationship to Guarantor

Date of Birth

Gender:

First Name

Last Name Address

City

Employment Status (Circle One) Full-time

Part-time

M

F

SSN

Disabled

State

Retired

Not Employed

Self Employed

Zip On Active Duty

Employer Phone

Employer Name Phone:

Alternate Phone

Email

NEXT OF KIN (Emergency Contact Person Information) Patient Relationship to NOK

Date of Birth

Last Name

First Name Alternate Phone

Phone:

MI __________

Email

Employer Name

Employer Phone

Alternate Contact Information Patient Relationship to Contact Person

Date of Birth

Last Name

First Name Alternate Phone

Phone:

MI __________

Email

INSURANCE INFORMATION Member Name

Date of Birth

SSN

Group #

Name of Insurance Member ID:

Address

City

Employer Name

State

Zip

Employer Phone Secondary Information Date of Birth

Member Name SSN Reg Non-Conf

*90932* 90932

Group #

Address

Member ID: City

Employer Name

93333 (0914)

Name of Insurance State

Zip

Employer Phone © 2014 Indiana University Health