Patient Registration

Patient Registration

"*" indicates required fields

Patient Information

MM slash DD slash YYYY
Patient Name*
MM slash DD slash YYYY
Patient Address*
Choose clinic because/Referred to clinic by*

Please indicate one box.

Insurance Information

Enter "N/A" if you are uninsured.
Are you uninsured?*

Primary Care Provider Information

(Please bring your insurance card to the receptionist.)
If you do not have a primary care doctor, please type N/A.
Primary Care Provider Address*

Pharmacy Information

(Please bring your insurance card to the receptionist.)
Please include street, city, and zip code

In Case of an Emergency

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.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.