New Patient Registration Form
| Dr. Martin Blackwell |
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| Please present your insurance card(s), credit card and a Photo ID to the receptionist along with this completed form. Thank you. |
This section must be completed for all patients: Todays Date:__/__/__
Primary Physician:______________________
Name:___________________________________________________
Last First MI
Date of Birth:__/__/__ Age:__ Sex: Male Female Marital Status: M S D W
Mailing Address
_______________________________________________________________
City State Zip
Home Phone: ( )______________ Cell Phone: ( )_______________
Work Phone: ( )______________ Social Security #:__________________
Parent, Spouse or Responsible Party (if different from patient)
Name:_________________________________ Date of Birth:__/__/__
Address:________________________________________________________
Home Phone: ( )______________ Work Phone: ( )______________
Insurance Coverage - Primary
Insurance Co. Name:___________________________ Policy Type: HMO PPO
Policy #_____________________________ Group Name or #:_______________
Name of Policy Holder (insured):_____________________________
Policy Holder Date of Birth:__/__/__ Social Security #:________________
Relationship to Insured: Spouse Child Self Other__________
Insurance Coverage - Secondary
Insurance Co. Name:___________________________ Policy Type: HMO PPO
Policy #:___________________________ Group Name or #:______________
Name of Policy Holder:______________________________________________
Policy Holder Date of Birth:__/__/__ Social Security #:_______________
Relationship to Insured: Spouse Child Self Other________________
MANAGED CARE/PPO/HMO OR MEDICARE PATIENTS
I assume responsibility for any service that is not approved on my referral(if such form is
required by my plan); any service which is cosmetic in nature and/or not covered by my insurer;
any visit for which I have not presented a valid referral on the day of service or is not ultimately
covered by my insurer. I assign payment benefits for my primary, secondary and/or medigap
plan to this provider. Any deductible, copayment or coinsurance designated by my plan is my
responsibility. I do hereby agree to pay Dr. Martin Blackwell the amount of any and all bills for
services rendered to the above named patient not covered by my insurance into which the
physician has entered into an agreement. I hereby authorize the release of information
necessary to file a claim with my insurer, and/or which case to any insurance company
involved in my care. A copy of this signature is as valid as the original. Patient accounts
that are past due beyond 60 days will incur a $25.00 monthly fee
X________________________________________________ _________
Signature of patient/patients parent or guardian required Date
Allergies to medications:__________________________________________
Do you have a history of: Yes No Yes No
List all Hospital Admissions:
________________________________________________________________
Please list all current illnesses/medical conditions:
________________________________________________________________
________________________________________________________________
Please list all medications you are taking (oral, external, topical, creams,
lotions, birth control, vitamins, herbs,
etc.)____________________________________________________________
________________________________________________________________
Privacy Consent-Do we have permission to (please answer all the
following questions)
__________________________ _______________________ __________
Credit Card Acknowledgement
(please give your credit card to the receptionist if signing)
By signing your name below, you are acknowledging that you have given
Dr. Martin Blackwell permission to photocopy your credit card for billing
purposes, if needed. Our office acknowledges that we will protect this
information, as it will become part of your personal medical record.
____________________________ ______________
Signature (patient or legal guardian) Date00
Primary Physician:______________________
Name:___________________________________________________
Last First MI
Date of Birth:__/__/__ Age:__ Sex: Male Female Marital Status: M S D W
Mailing Address
_______________________________________________________________
City State Zip
Home Phone: ( )______________ Cell Phone: ( )_______________
Work Phone: ( )______________ Social Security #:__________________
Parent, Spouse or Responsible Party (if different from patient)
Name:_________________________________ Date of Birth:__/__/__
Address:________________________________________________________
Home Phone: ( )______________ Work Phone: ( )______________
Insurance Coverage - Primary
Insurance Co. Name:___________________________ Policy Type: HMO PPO
Policy #_____________________________ Group Name or #:_______________
Name of Policy Holder (insured):_____________________________
Policy Holder Date of Birth:__/__/__ Social Security #:________________
Relationship to Insured: Spouse Child Self Other__________
Insurance Coverage - Secondary
Insurance Co. Name:___________________________ Policy Type: HMO PPO
Policy #:___________________________ Group Name or #:______________
Name of Policy Holder:______________________________________________
Policy Holder Date of Birth:__/__/__ Social Security #:_______________
Relationship to Insured: Spouse Child Self Other________________
MANAGED CARE/PPO/HMO OR MEDICARE PATIENTS
I assume responsibility for any service that is not approved on my referral(if such form is
required by my plan); any service which is cosmetic in nature and/or not covered by my insurer;
any visit for which I have not presented a valid referral on the day of service or is not ultimately
covered by my insurer. I assign payment benefits for my primary, secondary and/or medigap
plan to this provider. Any deductible, copayment or coinsurance designated by my plan is my
responsibility. I do hereby agree to pay Dr. Martin Blackwell the amount of any and all bills for
services rendered to the above named patient not covered by my insurance into which the
physician has entered into an agreement. I hereby authorize the release of information
necessary to file a claim with my insurer, and/or which case to any insurance company
involved in my care. A copy of this signature is as valid as the original. Patient accounts
that are past due beyond 60 days will incur a $25.00 monthly fee
X________________________________________________ _________
Signature of patient/patients parent or guardian required Date
Allergies to medications:__________________________________________
Do you have a history of: Yes No Yes No
List all Hospital Admissions:
________________________________________________________________
Please list all current illnesses/medical conditions:
________________________________________________________________
________________________________________________________________
Please list all medications you are taking (oral, external, topical, creams,
lotions, birth control, vitamins, herbs,
etc.)____________________________________________________________
________________________________________________________________
Privacy Consent-Do we have permission to (please answer all the
following questions)
__________________________ _______________________ __________
Credit Card Acknowledgement
(please give your credit card to the receptionist if signing)
By signing your name below, you are acknowledging that you have given
Dr. Martin Blackwell permission to photocopy your credit card for billing
purposes, if needed. Our office acknowledges that we will protect this
information, as it will become part of your personal medical record.
____________________________ ______________
Signature (patient or legal guardian) Date00
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