Patient Registration

Welcome to Bozeman Creek Family Health. We are committed to providing the best, most comprehensive care possible. Please assist us by providing the following information. All information is confidential and only released with your consent.

Thank you for allowing us this opportunity to care for you!

Patient Information

Patient Name:

Todays Date:

Date of Birth:

Sex:

Gender:

Social Security:

Preferred Language:

Ethnicity:

Hispanic

Non Hispanic

Race

White

Black

Asian

Indian / Alask

Pac isle

Other / Mult

Parent(s) / Guardian(s) Name (Minors Only):

Mailing/Billing Address:

City:

State:

Zip Code:

Primary #:

Secondary #:

Employer:

Work #:

Email:

Would you like to receive your billing statements via email?

Yes

May we leave clinical messages or healthcare information on the following

Answering machine/Voicemail?

Yes

Number #

Email:

Yes

Email:

How were you referred to our practice?

Doctors Office

Current Patient / Friend

Insurance

Phone Book

Website

Event

Internet Search

Other

In Case of An Emergency Please Contact

Name

Relationship

Phone #

Financial Information

Insurance Company:

Policy #:

Group #:

If you are NOT the policy holder on your insurance account, please fill out the following

Subscriber:

Subscriber DOB:

E-Signature

Please sign electronically below.

Submit Signature Clear Signature

E-Signature Consent

You have signed this document electronically. You hereby confirm that you are consent to signing this document electronically.