AFFZ11 Patient Registration Form

Patient Registration

Personal Information

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Address *

Street Address

Apartment or Unit Number

City

State / Province

Postal / Zip Code

Primary Phone Number *

Please enter a valid phone number.

Primary Phone Number is *

Home

Cell

Secondary Phone Number (if applicable)

Please enter a valid phone number.

Preferred contact method (check all that apply) *

Phone

Text

Email

Email *

example@example.com

Emergency Contact Information

Name *

First Name

Last Name

Relationship to Patient *

Phone Number *

Please enter a valid phone number.

Guarantor Information

Please select one of the following: *

Check here if the PATIENT is financially responsible.

Check here if anyone OTHER THAN THE PATIENT is financially responsible, then please fill out the information below

Name *REQUIRED*

First Name

Last Name

Address *REQUIRED*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Primary Phone Number *REQUIRED*

Please enter a valid phone number.

Birthdate of Responsible Party *REQUIRED*

Date

Race

Ethnicity

Language

Digital SignatureAuthorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Patient or Legal Representative *

Name of Legal Representative, if other than the patient

First Name

Last Name

Relationship to Patient

Date *

Date