Patient Registration Form

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

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* 1. Patient name

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* 2. Email

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* 3. Phone number

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* 4. Address

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* 5. Date of Birth

Date

Date

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* 6. Gender

Male

Female

Non-binary

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* 7. Primary Care Physician (PCP)

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* 8. Primary Care Physician (PCP) phone number

Health History

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* 9. Currently taking any medications?

Yes

No

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* 10. Reason for patient registration

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* 11. Preferred Pharmacy

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* 12. Pharmacy Phone Number

Emergency Contact

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* 13. Emergency Contact

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* 14. Relationship

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* 15. Emergency Contact Phone Number

Insurance Information

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* 16. Insurance Company

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* 17. Insurance ID

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* 18. Policy Holder's Name