Patient Registration Form – The Urgency Room

Patient Information

 Patient Full Name:
□ New Patient □ Existing Patient
Reason for Visit:
Date of Birth:                                   Gender: □ Male □ Female
Social Security #:                            Ethnicity/Race:
Local Address:                                 Apt #:
City:               State:                   Zip:
Primary Phone #:                                    □ Home □ Cell □ Work
Secondary Phone # :                               □ Home □ Cell □ Work
Email Address: By providing your email address, you consent to our Email Privacy Policy
How did you hear about us?

□ Location        □ Customer Service      □ Email      □ Facility Signage

□ Family/Friend/Word of Mouth     □ Internet/Online Search      □ Print Advertising

□ Radio         □ Phone Book/Yellow Pages

□ School/Daycare: ___________________ □ Employer: ___________________

□ Community Event: _________________ □ Hotel: ______________________

□ Physician Referral: _________________ □ Pharmacy: ___________________

□ Apartment Complex: _______________ □ Insurance: ___________________

Marital Status:   □ Child   □ Single   □ Married   □ Divorced    □ Widowed □ Separated
Spouse’s Full Name:
Permanent Address (other than local):
City:                         State:                        Zip:
Primary Care Physician:
Employer:

Insurance Subscriber Information – Complete Only if NOT the Patient

Insured Subscriber Full Name ___________________

Subscriber’s Date of Birth ____________________

Subscriber’s Social Security # _________________________

Subscriber’s Relationship to Patient __________________________

Subscriber’s Permanent Address ____________________   APT _______________

City ______________________  Street_____________________ Zip_______________

Subscriber’s Primary Phone ______________________________

Subscriber’s Secondary Phone ____________________________

Subscriber’s Employer _______________________________

Complete Insurance Details

Insurance Company ________________________________

Type _____ HMO / ______ PPO    _____ Medicaid/AHCCCS    ______ Tricare   ______ Other

ID / Policy # ______________________ Group# ____________________________

Copay/Coins/Ded Admont_______________________________  Effective Date________________

Secondary Insurance ____ Yes   ____ No      Name___________________________

Parent / Legal Guardian of Minor or Incapacitated Adult Only

Full Name ___________________   Date of Birth _________________________

Relationship _____________________    Contact #_____________________________

Signature

Patient’s Name________________________________   Date___________________________

Signature:

©The Urgency Room, Inc. Updated: 07/01/16