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Medical Registration Form
Medical Registration Form Login Account (optional)
New Users / Returning Users
CLICK HERE
to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.
Patient Information
First Name
*
Initial
Last Name
*
Date of Birth
*
+
Email Address:
*
Cell Phone Number
*
Home Phone Number
Alternative Phone Number
Where can we send appointment reminders to?
*
Email
Text My Cell Phone
Marital Status
*
Single
Married
Other
Other
Gender
*
Male
Female
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Is this your first treatment at Stay Fit?
*
Yes
No
Please describe previous treatments:
*
How did you hear about us?
*
Doctor Referral
Internet Search
Friend/Family
Other
Other
Emergency Contact:
Emergency Contact:
*
Phone Number
*
Relationship:
*
Spouse
Parent
Friend
Other
Alternative Phone:
Cell
Work
Other
Referring Physician Information:
MD Name:
*
MD Address:
Phone:
*
Fax:
Reason for Visit:
Is this an accident related condition?
*
Yes
No
Please indicate accident reason?
*
Workers Compensation
Car accident
Home accident
Job related
Other
Other
Date of injury:
*
+
Date of first symptom:
*
+
Describe injury:
*
Payer Information:
Primary Insurance Company Name:
*
Aetna
Blue Cross Blue Shield of Illinois
Cigna
Humana
Medicare
United
Other
Other
Insured's Name:
*
Insured Date of Birth:
*
+
Phone Number of Insured person:
*
Relationship to patient:
*
Self
Spouse
Child
Other
Other
Policy ID Number:
*
Group Number:
Insurance Phone:
🛈
Do you have a secondary insurance?
*
No
Yes
Secondary Insurance Company Name:
*
AARP
Aetna
Blue Cross Blue Shield of Illinois
Cigna
Humana
Medicare
United
Other
Other
Insured's Name:
*
Insured Date of Birth:
*
+
Relationship to patient:
*
Self
Spouse
Child
Other
Other
Phone Number of Insured person:
*
Policy ID Number:
*
Group Number:
Insurance Phone:
🛈
Check this Box if you would like to upload front & back copies of your insurance cards
Front and back copies of your insurance card(s)
🛈
Property of Stay Fit Physical Therapy & Core Wellness, Inc.
Written authorization for use is required.
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