Preregistration Form

Patient Information
Patients legal name
Last name
First name    M.I.
New Patient
Established Patient
Medical Diagnosis/Reason for Appointment
Has Prior Assessments?
If Yes, When/Where?
Primary Care Physician
Referring Physician
Preferred Neuropsychologist
Date of Birth / / mm/dd/yyyy
Age in Years  
Months
Days If less than a year old
Gender

Legal Guardian/ Guarantor
Last name
First name     M.I.
Address Line 1
Address Line 2
City
State     Zip Code
Best Contact Number: . .
Home Phone . .
Guarantor e-mail address
Religion
Language
Need interpreter

Parent Information
Last name
First name     M.I.
Relation to Patient
Date of Birth / / mm/dd/yyyy
Address Line 1
Address Line 2
City
State     Zip Code
Best Contact Number: . .
Home Phone . .
E-mail Address
Employer id
Occupation
Work Phone . .     Ext.
Other Phone . .
 
Secondary contact
Last name
First name     M.I.
Relation to Patient
Best Contact Number: . .
Home Phone . .

Insurance Information
Insurance Plan Name
Insurance Type
Insurance effective date / / mm/dd/yyyy
Insurance group name
Policy#  
Group# Enter 00 for no group#
Policy Holder
Policy Holder Date of Birth / / mm/dd/yyyy
Patient's Relationship to the Insured
Insured Employee Status
Insured's Employer
Skip claim address if insurance is Medicaid.
Claims Address
Address Line 1
Address Line 2
City
State     Zip Code
Benefits/Customer Service Phone Number . . From your insurance card

Secondary Insurance Information If applicable please enter
Insurance Plan Name
Insurance Type
Insurance effective date / / mm/dd/yyyy
Insurance group name
Policy#  
Group# Enter 00 for no group#
Policy Holder
Policy Holder Date of Birth / / mm/dd/yyyy
Patient's Relationship to the Insured
Insured Employee Status
Insured's Employer
Skip claim address if insurance is Medicaid.
Claims Address
Address Line 1
Address Line 2
City
State     Zip Code
Benefits/Customer Service Phone Number . . From your insurance card