Patient Sticker Here
Ambulatory Registration PATIENT DEMOGRAPHIC INFORMATION Legal Name
Date of Birth
Address
City
County of Residence Preferred Language of Communication: Gender:
M
F
State
Country English
Zip
SSN
Spanish
Other
Marital Status
Race:
American Indian or Alaska Native White Multiracial
Ethnicity:
Hispanic or Latino
Phone
Asian Unknown
Black or African American Declined
Not Hispanic or Latino
Declined
Alternate Phone
Preferred Method of Communication:
Email
Native Hawaiian or other Pacific Islander Unknown
Email Address Mail
Home Phone
Primary Care Doctor
Cell Phone
Work Phone
Declined
Referring Doctor
Employment Status (Circle One) Full-time
Part-time
Disabled
Retired
Not Employed
Employer Name
Self Employed
On Active Duty
Employer Phone
Retirement Date (if applicable) Is visit due to accident? Accident:
If yes, Accident Type
Date
Time
Location
PATIENT GUARANTOR INFORMATION (Complete if other than patient) Patient Relationship to Guarantor
Date of Birth
Gender:
First Name
Last Name Address
City
Employment Status (Circle One) Full-time
Part-time
M
F
SSN
Disabled
State
Retired
Not Employed
Self Employed
Zip On Active Duty
Employer Phone
Employer Name Phone:
Alternate Phone
Email
NEXT OF KIN (Emergency Contact Person Information) Patient Relationship to NOK
Date of Birth
Last Name
First Name Alternate Phone
Phone:
MI __________
Email
Employer Name
Employer Phone
Alternate Contact Information Patient Relationship to Contact Person
Date of Birth
Last Name
First Name Alternate Phone
Phone:
MI __________
Email
INSURANCE INFORMATION Member Name
Date of Birth
SSN
Group #
Name of Insurance Member ID:
Address
City
Employer Name
State
Zip
Employer Phone Secondary Information Date of Birth
Member Name SSN Reg Non-Conf
*90932* 90932
Group #
Address
Member ID: City
Employer Name
93333 (0914)
Name of Insurance State
Zip
Employer Phone © 2014 Indiana University Health
