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PATIENT REGISTRATION FORM

    Patient Information:
    First Name:
    Last Name:
    Date of Birth:
    Gender:
    Marital Status:
    Social Security Number:
    Contact Number:
    Email:
    Address:
    City:
    State:
    Zip Code:

    Emergency Contact:
    Emergency Contact Name:
    Relationship to Patient:
    Emergency Contact Number:

    Insurance Information:
    Primary Insurance Provider:
    Primary Policy Number:
    Primary Group Number:
    Secondary Insurance Provider:
    Secondary Policy Number:

    Health History:
    Allergies:
    Chronic Conditions:
    Current Medications:
    Past Surgeries:
    Family Medical History:

    Lifestyle Information:
    Smoking Status: Current SmokerFormer SmokerNever Smoked
    Alcohol Consumption: RegularlyOccasionallyNever
    Exercise Frequency:

    Authorization and Consent:
    I authorize the use and disclosure of my health information as described in the Privacy Notice.
    I consent to the examination and treatment by the healthcare providers at this facility.

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