Patient Registration Form All fields marked with an asterisk(*) are mandatory. Location*Pompton PlainsSayreville/South AmboyHow did you hear about us?Drive by/ SignageInsurance DirectoryFriend/ Family Member/ Co-WorkerMail AdvertisementPatient's Name* First Name Last Name What day would you like to be seen? Time? : HH MM AM PM Email Authorization to communicate via email Yes Date of Birth* Marital StatusChildSingleMarriedDivorcedWidowedSeparatedSex*MaleFemaleAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Was this the cause of a motor vehicle accident?NoYesCell Phone*Home Phone #*Emergency Contact Phone#*Relationship to PatientWork Related Injury Yes Patient's Employer*Employer's Phone #*Primary Care PhysicianPrimary Care Phone #Pharmacy Name*Pharmacy Location* Pharmacy City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Pharmacy State Pharmacy Phone #DemographicsBased on government regulations we are required to ask the following information: Preferred LanguageRaceAmerican Indian or Alaska NativeAsianDecline to answerEthnicityHispanic or LatinoBlack or African AmericanCaucasianNon-Hispanic or LatinoNative Hawaiian or Other Pacific IslanderDecline to answerGuarantor InformationCheck if same as patient information and sign below. If not, please complete entire section and sign.Same as patient information? Yes Name* First Name Last Name SexMaleFemaleRelationship to PatientSelfSpouseChildParentOtherDate of Birth Guarantor EmployerStreet AddressEmployer Phone #Home Phone #Local Phone or Cell #Insurance InformationPrimary InsuranceInsurance Plan Name*Relationship to PatientSelfSpouseChildParentOtherPolicy ID #*Group #Same name as patient? Yes Subscriber's Name First Last Subscribers Date of Birth* Secondary InsuranceInsurance Plan NameRelationship to PatientSelfSpouseChildParentOtherPolicy ID #Group #Same name as patient? Yes Subscriber's Name First Last Subscribers Date of Birth AUTHORIZATION AND RELEASEAuthorization for treatment: I voluntarily consent to the administration and cost of medical and surgical procedures for myself or my dependent. Assignment of insurance benefits: I authorize payment direct to NJ Doctors Urgent Care, LLC for all benefits otherwise payable to me. Guarantee of Payments: I understand that I am financially responsible and agree to pay all charges that are not paid or billed to insurance or any other third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance accepted, I must pay all applicable insurance co pays, coinsurances and deductibles today. If you are unable to verify my insurance at time of services, I will in full for all services. Release of Records: I authorize NJ Doctors Urgent Care, LLC to release (verbal or in writing) confidential medical information to any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operation which may be liable to me or my practitioners for charges for this treatment and for quality management, utilization review, transfer, and follow up purposes. Receipt of Privacy Practices: I acknowledge that I have received and read the Notice of Privacy Practices of NJ Doctors Urgent care, LLC. I understand that copy of this agreement may be used with the same effectiveness as the original. CONSENT FOR TREATMENT: I, the undersigned, consent to the care and treatment by the attending physician, his/her associates or assistants. I acknowledge that no guarantees have been made as to the effect of such treatment.SignaturePhoneThis field is for validation purposes and should be left unchanged.
