subject_line
Hanger Clinic Patient Registration Form
SECTION 1: PATIENT INFORMATION
PERSONAL INFORMATION
Please select:
Mr
Ms
Mrs
Mx
First Name:
*
Middle Initial:
*
Last Name:
*
DOB:
*
+
Sex:
*
Male
Female
Marital Status:
*
Address:
*
City:
*
State:
*
Zip:
*
Primary Phone Number:
*
Phone Type
*
Cell
Home
Work
Other
Other
Secondary Phone:
Phone Type
Cell
Home
Work
Other
Other
Email Address:
Confirm Email:
GUARANTOR INFORMATION
Is patient also the guarantor?
*
Yes
No
Guarantor Name:
*
Guarantor Phone:
*
Relationship to Patient:
*
Spouse
Child
Other
Other
Is guarantor address the same as patient?
*
Yes
No
Guarantor Address:
*
City:
*
State:
*
Zip:
*
EMERGENCY CONTACT INFORMATION
Name:
*
Relationship to Patient:
*
Phone Number:
*
PHYSICIAN INFORMATION
Referring Physician:
*
Practice Name:
Phone:
*
Is the Referring Physician also your Primary Care Physician?
*
Yes
No
Primary Care Physician:
*
Practice Name:
*
Phone:
*
CONDITION INFORMATION
Are you diabetic?
*
Yes
No
Is the physician treating your diabetes the same as your Referring Physician?
*
Yes
No
Is the physician treating your diabetes the same as your Referring Physician or Primary Care Physician?
*
Yes - Referring Physician
Yes - Primary Care Physician
No
Please provide the name and phone number of physician treating your diabetes:
Physician Name:
*
Phone:
*
Have you received a similar service in the past five years?
*
Yes
No
Are you in hospice care?
*
Yes
No
Are you a resident of a skilled nursing (nursing home) facility?
*
Yes
No
Facility Address:
*
City:
*
State:
*
Zip:
*
Was your condition the result of an accident?
*
Yes
No
Was your injury work related?
*
Yes
No
Date of Injury:
*
+
Please provide the following for your employer at time of accident:
Employer Name:
*
Address:
*
City:
*
State
*
Zip:
*
Contact Person:
*
Phone:
*
Claim #:
Was your injury the result of an automobile accident?
*
Yes
No
Date of Accident:
*
+
Please provide the following for the insurance adjuster:
Name (Agent or Company):
*
Phone Number:
*
Claim #: