Mercy Clinic Infectious Disease
REGISTRATION FORM

Date of Appointment: ___________________

PATIENT DEMOGRAPHICS	

Name: _________________________________________________	SSN: _________________________________

Sex:  Male    Female	Birth date: _____________________	

Patient Address
Address: ________________________________________________	Home Phone: ___________________________
	  ________________________________________________	Work Phone: ___________________________
City: 	  ________________________________________________	Cell Phone: ____________________________
State:	  ________________		Zip: ____________________	E-mail: ________________________________

Best Contact # for Appointment Reminders:______________________________________________________________

Preferred Communication Method:    Mail            My Mercy

□ Married		   □ Separated			□ Divorced  			□ Life Partner

Spouse:_________________________________________ Date of Birth:___________________________

Spouse 
Phone Number:____________________________

Patient Employer:_______________________________________            Full-Time    Part-Time 

Address:______________________________________________

_____________________________________________________

PRIMARY CARE PROVIDER INFORMATION	

Primary Care Physician: ________________________________________________
Phone Number:______________________________________________
Referring Doctor’s Name:______________________________________
Referring Doctor’s Phone number:_______________________________

RESPONSIBLE PARTY/GUARANTOR	

Name: _____________________________________________  DOB: _____________  SSN:______________________
Address: _____________________________________________
	  _____________________________________________
City: 	  _____________________________________________
State: 	  __________________		Zip: _________________	Phone: ________________________________
Relationship to Patient: ______________________________________________________________________________

EMERGENCY CONTACT INFORMATION	

Name: _________________________________________________	Home Phone: ___________________________
Address: _______________________________________________	Work Phone: ___________________________
	  _______________________________________________	Cell Phone: ____________________________
	  _______________________________________________	Relationship to Patient: ___________________
City: 	  _______________________________________________	State: _____________________Zip:_________ 

SUBSCRIBER ACCOUNT INFORMATION	

Insurance Coverage:
Insurance Name:___________________________________________________________________________________ 
Insurance Effective Date:____________________________________________________________________________  	
Subscriber Name:__________________________________________________________________________________  
Subscriber DOB:___________________________________________________________________________________ 
Subscriber Employer:_______________________________________________________________________________  

Secondary Insurance Name:_________________________________________________________________________
Secondary Insurance Effective Date:___________________________________________________________________
Secondary Subscriber Name:_________________________________________________________________________
Secondary Subscriber DOB:__________________________________________________________________________
Secondary Subscriber Employer:______________________________________________________________________