PATIENT REGISTRATION FORM

PATIENT'S NAME:________________________________________________________DATE:___________

ADDRESS:_________________________________City:______________State:________Zip____________

TELEPHONE:(hm)______________________(wk)_______________________ DATE OF BIRTH:_________

AGE:_________MARITAL STATUS:___S___M___W___D___ REFERRED BY: _______________________

EMPLOYER NAME & ADDRESS_________________________________OCCUPATION:_______________

EMPLOYER TELEPHONE: (___)____________________ SPOUSE NAME:___________________________

PARENT OR SPOUSE'S EMPLOYER:_______________________ TELEPHONE: (___)_________________

EMERGENCY CONTACT PERSON :_________________________ TELEPHONE: (___)________________

NOTE TO DIVORCED PARENTS: It is the policy of this office that the parent accompanying the child for treatment will be held 

responsible for all bills. We cannot bill the other parent.

PLEASE READ THIS: All professional services rendered are charged to the patient. Necessary forms will be completed to 

expedite insurance carrier payment. The patient is responsible for all fees, regardless of  insurance coverage.  It is customary 

to pay for services when they are rendered unless other arrangements have been made in advance.

Mother's Maiden Name:________________________________

Your Social Security NO. ________-______-_________ 

Please tell us how you prefer to be addressed (first name, last name, title, etc.)________________________

DO YOU HAVE ANY DRUG ALLERGIES?_____________________________________________________

I hereby authorize Ralph B. Martin, M.D. to furnish information to insurance carriers concerning my illness and treatments 

including HIV and Hepatitis C tests and results, and I hereby assign to the physician all payments for medical services 

rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance. 

SIGNATURE OF PATIENT:______________________________________________DATE:_____________

SIGNATURE OF INSURED: _____________________________________________DATE:_____________

* WE DO NOT VALIDATE PARKING *