Transcription of PATIENT REGISTRATION / ENCOUNTER FORM
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PATIENT REGISTRATION / ENCOUNTER FORM
P. (210) 614-4544 F. (210) 679-3725 PATIENT REGISTRATION / ENCOUNTER form REV. 11/12/2015 Appointment Date/Time Medical Provider Appointment Reason/Memo Co-Pay OFFICE USE PATIENT Information PATIENT Address Account # OFFICE USE Date of Birth City Age State Gender Zip Doctor Marital Status Social Security # Home Phone Preferred Language Work Phone Race Cell Phone Ethnicity Email Referred By Highest Education Primary Physician Primary Physician Address Office Phone Fax Insurance Information (including Medicare and/or Medicaid) Primary Insurance Secondary Insurance Policy # Policy # Group # Group # Insured s Name Insured s Name Insured s Insured s Insured s Gender Insured s Gender Pharmacy Information and Emergency Contact Information Preferred Pharmacy Emergency Contact Address/Intersection Relationship City, State, Zip Primary Number Phone # Secondary Number MEDICAL HISTORYC urrent Medications List all medicati
PATIENT REGISTRATION / ENCOUNTER FORM REV. 11/12/2015 Appointment Date/Time Medical Provider Appointment Reason/Memo Co-Pay OFFICE USE Patient Information . Patient Address Account # OFFICE USE Date of Birth City Age State ... Patient Name (Printed) Date of Birth . I authorize Urology San Antonio to discuss and/or release my protected health ...
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