New Patient Registration
Form
Cartersville Ob/Gyn Associates
Enter your
information in the fields (textboxes) on this page, type your response to all
requested information, and then click the submit button to send the completed form to our
office prior to your visit. Use the Tab Key to move from field to field. You don't
have to sign it now - we'll ask you to do that in our office. If you have questions,
please contact our office (770-386-4824) and ask us. Thank you!
Patient's
full name (First Middle Last):
Address (Street City State Zip):
Home
Phone: ()
Work Phone: ()
DOB: (xx/xx/xxxx) Age:
Patient's Social Security #:
Driver's License #:
State:
Marital Status: S M D W
Patient's Employer:
Employer's Address (Street City State Zip):
Spouse or Parent's Name:
Home Phone:
Work Phone:
Employer:
Address:
Who is the insurance policy holder?:
Self Spouse Parent:
Mother Father
Name of Policy Holder:
Insurance Name:
SSN # or Policy ID#:
Employer of Policy Holder:
DOB:
Do you have a PRIMARY CARE PHYSICIAN appointed by your insurance?:
Y N
Emergency contact (other than spouse):
Home Phone: ()
Work Phone: ( )
Please
select the practitioner you wish to see (click on name to highlight):
My
permission is granted to CARTERSVILLE OB/GYN Assoc. to disclose medical information to
other treating physicians regarding my care. I authorize the release of such
records for the purpose of obtaining reimbursement from my insurance company.
All medical/surgical benefits are assigned to CARTERSVILLE OB/GYN Assoc. for billed
services. I understand that I am financially responsible for charges related to medical
and/or surgical services.