Tuesday, April 24, 2018
Patient Registration Form Step 1
Please fill out the form below as accurately as possible. This enables us to process our records much more efficiently, which enables us to better serve our patients. If you have any questions do not hesitate to contact us.

Family Health Care Associates of Greenbrier collects and uses your personal information to operate our clinic and deliver the services you have requested. We will not share your personal to any third party source, as it is strictly used for our patient records.
Today's Date:*
Last Name:*
First Name:*
Middle Initial:*
Sex:*
SSN:*
Date of Birth:*
Occupation:*
Address:*
City:*
State:*
Zipcode:*
Cell Phone:
Work Phone:
Emergency Contact:*
Emergency Phone:
Employer:
Employer's Address:
Spouse and/or Responsible Party (If other than patient):
Responsible Party Address:
Responsible Party Employer:
Responsible Party DOB:
I am:*
Primary Insurance:*
Secondary Insurance:
Insurance Authorization: I assign to the Provider any and all benefits from any insurance plans and direct and authorize such benefits to be paid directly to the Provider. I authorize the release of any medical information necessary to process any insurance claim.
Who may we leave messages with
at your home or work?
May we leave appointment reminder messages on your answering machine?
Home:*
Work:*
May we leave account balance information on your answering machine?
Home:*
Work:*
May we send your lab and pathology results by mail?*
If you answered NO to any of the previous questions, is there another number where we may leave messages regarding appointments, account information, lab, and pathology results?
Contact Name/Phone:
By clicking the SUBMIT button below you hereby authorize us to collect the sent data for pre-registration purposes.
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