Patient Registration

"*" indicates required fields

Patient Information

Today's Date*

Email*

Patient Name*

First Middle Last

Patient Date of Birth*

Last 4 Digits of Social Security Number*

Patient Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Occupation*

Employer*

Employer Phone*

Choose clinic because/Referred to clinic by*

Please indicate one box.

Gender*

Marital Status*

Insurance Information

Enter "N/A" if you are uninsured.

Insurance Carrier*

Group Number*

Policy Number*

Subscriber Name and DOB if not you:*

Are you uninsured?*

Yes

Primary Care Provider Information

(Please bring your insurance card to the receptionist.)

Primary Care Provider*

If you do not have a primary care doctor, please type N/A.

Primary Care Provider Phone*

Primary Care Provider Address*

Street Address Address Line 2 City State ZIP Code

Pharmacy Information

(Please bring your insurance card to the receptionist.)

Primary Pharmacy*

Pharmacy Address*

Please include street, city, and zip code

In Case of an Emergency

Name*

Relationship*

Accessible Phone Number*

Secondary Phone if Applicable

Sign & Date

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Allure Health or insurance company to release any information required to process my claims.

Signature*

Today's Date*

Phone

This field is for validation purposes and should be left unchanged.

Patient Registration