Patient Registration Form

patient registration

You may use this form if you are a new patient. This form collects all necessary personal information.

Patient information

Please indicate your physical address.

Date of Birth:

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Please complete the required fields highlighted in red

Treatment Authorization

I hereby consent to and authorize any medical treatment as deemed necessary by Palm Glades Rural Health Associates.

Signature:

(Parent or guardian signature if under 18 years)
Valid until rescinded in writing.

Date:

Please complete the required fields highlighted in red

Payment Type

Cash

Insurance

Financial Policy

Unless advance arrangements are made, payment of services is expected at the time they are rendered. As the patient/parent, you are responsible for any charges incurred. Medicaid patients must be eligible at the time of service. We accept assignment of Medicare and require 20% coinsurance after the deductible has been met

Phone Numbers

Primary Phone:

(

)

Work Phone:

(

)

Emergency Contact:

Primary Phone:

(

)

Work Phone:

(

)

Please complete the required fields highlighted in red

How did you hear about us?

Facebook

Twitter

Radio

Friends

Employer

Others:

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I, certify that the information I have provided above is true and correct and I have read, understand and agree to all

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Submit Registration