Registration Form My ob/Gyne Today’s Date



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Patient Registration Form My OB/Gyne
Today’s Date: ______________________________

Patient Information: Patient’s E-mail: ________________________________________________
Last Name: ______________________________________________ First Name: ____________________________________________ Middle Initial: _________________
Date of Birth: ______________________ Social Security # ___________________________________ Home Phone: ____________________________________________
Street Address: ________________________________________________ City: _____________________________________ Zip Code: ____________________________
Work Phone: ____________________________________ Cell Phone: __________________________________ Patient Referred By: __________________________________
Marital Status: _____ Single _____ Married _____ other (widow, divorced, separated) Patient PCP: _____________________________________________________________
Spouse’s Name: ____________________________________ Spouse’s Phone: ______________________________________
Employer Information:
Employer Name: __________________________________________________ Employer Address: ______________________________________________________________
Occupation: ______________________________________________________ Employer Phone: ________________________________________________________________
Emergency Contact Information:
Last Name: ________________________________ First Name: ___________________________ Phone: _________________________ Relationship: _____________________
Insurance Information:
Insurance Plan Name: ___________________________________________ Policy ID: ____________________________________ Policy Group ID: ______________________
Policy Holder Name: ______________________________________ Policy Holder DOB: ________________________ Policy Social Security #: __________________________
Policy Holder Employer:___________________________________ Policy Holder Employer Address: ____________________________________________________________
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Please read each of the following statements carefully and sign as your authorization, understanding and agreement to each statement.
ASSIGNMENT AND RELEASE: I hereby assign my insurance benefits to be paid directly to the physician. I also authorize the physician to release any information required to process claims to my employer, prospective employer and/or insurance carrier.
Signed: _____________________________________________________________ Date: ____________________________________
MEDICARE BENEFICIARY ASSIGINMENT AND RELEASE: I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by Dr. Vidalia Butler-Poku, M.D. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
Signed: _____________________________________________________________ Date: ____________________________________
FINANCIAL OBLIGATION: I herby acknowledge that I understand there may be services provided that will not be covered by my insurance carrier, and fully understand that I am fully responsible for any and all charges not covered by my insurance carrier. I understand that payment may be requested at the time of service or I may be billed for such services subsequently.
Signed: _____________________________________________________________ Date: ____________________________________
CONSENT FOR TREATMENT: I hereby authorize the physician, nurses, medical assistants and staff to conduct such examinations, and to administer treatment and medications as they deem necessary and advisable.
Signed: _____________________________________________________________ Date: _____________________________________
ADVANCED DIRECTIVE: Do you have an advance directive (living will/power of attorney)?
_______ Yes ______ No If yes, please provide a copy for our records.

PATIENT COMMUNICATION
May we leave a message on your voice mail or answering machine? __________YES ____________ NO
Is there anyone other than yourself that you authorize us to speak with on behalf of your medical care? If so, please list name and relation:
_______________________________________________________________________ __________________________________________________________

Please Print Name Relationship
Do you have any other communication restrictions or authorization that you would like to make known? ______________________________________________________
________________________________________________________________________________________________________________________________________________


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