Patient Registration

"*" indicates required fields

Patient Information

Today's Date*

Email*

Patient Date of Birth*

Last 4 Digits of Social Security Number*

Name*

First Middle Last

Your 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.

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

Location of Pharmacy

In Case of an Emergency

Name*

Relationship*

Primary Phone*

Alternative Phone

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.