New Patient Registration Form

This is a demo site for CareneticDigital.com. This site is not intended for real patients.

"*" indicates required fields

First Name*

Middle Initial

Last Name*

What pronoun do you prefer to be addressed by*

She/Her

He/Him

They

Zie/Hir

Other

Other*

If minors (under age 18) is the patient, please complete below - Guardians required to provide supporting document

Parent/Guardian Last Name

Parent/Guardian First Name

Relationship to minor

Mother

Father

Guardian

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to minor

Mother

Father

Guardian

Sex at birth*

Female

Male

Date of Birth*

MM slash DD slash YYYY

Social Security #*

Preferred Health Provider*

Billing Address (street # or PO Box, city, state, zip)*

Street Address City State ZIP Code

Secondary Address (street # or PO Box, city, state, zip)*

Street Address City State ZIP Code

(i.e. temporary/permanent)

Primary Phone Number*

Secondary Phone Number*

Email*

Contact Preference*

Primary Phone

Secondary Phone

Email*

Text*

May leave voicemail message

Yes

* CareneticPT cannot guarantee the security of messages sent by email or text and by initialing here you consent to using email or text even with the risk that the messages may be intercepted and read by a third party. _______ (initial) You have the right to at any time request that CareneticPT communicate with you using alternative means or to alternative locations. Please ask for assistance if you are interested in changing your contact preferences.

Emergency Contact Name*

Relationship*

Emergency Contact Phone #*

Can we call Emergency Contact for Appointment Reminders?

Yes

Demographic Information

Some of the following questions may be uncomfortable for you to answer, however, your honest answer to the following questions will assist CareneticPT in providing the best services to you as an individual qualify for resources that support the services we provide.

Ethnicity*

Hispanic/Latino

Not Hispanic Latino

Race*

Alaska Native/ American Indian

Asian

Black/African American

Native Hawaiian/Pacific Islander

White/Caucasian

Other

Primary Language*

English

Spanish

Other

Marital Status*

Married

Single

Divorced

Widowed

Separated

Partner

Sexual Orientation*

Lesbian/Gay/Homosexual

Bisexual

Straight/Heterosexual

Don't want to disclose

Don't know/ Questioning

Other

Veteran*

Yes

What Branch*

Gender Identity*

Male

Female

Gender Variant/Inter-sex

Transgender: Male-to-Female

Transgender: Female-to-Male

Choose Not to Disclose

Other

Other*

Employment

Occupation*

Employer Name*

Employer Address*

Employer Phone Number*

Approximate Total Annual Household Income*

$0-$20,000

$21,000-$30,000

$31,000-$40,000

$41,000-$50,000

$51,000-$80,000

$81,000+

Number of People in your Household*

Other

(includes spouse and children, under 18 years old)

Other*

Insurance Information

Do you have health insurance?*

Yes

No (Skip to next Section)

Primary Plan Carrier Name

Primary Plan Carrier Phone Number

Policy #

Group #

Health Insurance Effective Date

MM slash DD slash YYYY

Policy Holder

Self

Other

Name of policyholder

Policyholder Date of Birth

MM slash DD slash YYYY

Do you have other insurance?

Yes

No (Skip to next section)

Secondary Plan Carrier Name

Secondary Plan Carrier Phone #

Secondary Policy #

Secondary Group #

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge I have received a copy of CareneticPT's Notice of Privacy Practices.

Patient Signature:

Missed Appointments/Late Cancellations

It is very important for you to keep all scheduled appointments. If you are unable to keep an appointment, you must notify us as soon as possible so we can use those appointment times for other patients. Three missed appointments will result in a standby appointment status and may lead to a dismissal from our clinic unless under special circumstances (ie. health crisis, epidemic, global pandemic, etc).

Consent to Film, Photograph and Record

By signing below, I consent to the filming, recording or photographing of me for the purposes of identification, treatment and for CareneticPT's internal operations, such as quality improvement and educating students and professionals. I understand I will not receive any compensation for any such films, recordings, or photographs.

Consent for Treatment and Agreements of Financial Responsibility

By signing below I am authorizing and consenting to all care and treatment provided by CareneticPT and its affiliated health care providers, which may include students, residents, volunteers and other trainees. Through this consent, I am authorization all care, including medical care, dental care, radiologic and diagnostic examinations, laboratory procedures and tests, and general medical and behavioral health care services requested or ordered by my health care provider. I understand that I may refuse services from a student, resident or trainee.

I authorize CareneticPT to submit claims for services rendered to my health insurer(s), including, Medicare, Medicaid, or other insurance company, and assign benefits payable for my services to CareneticPT. I understand that unless I am covered by an insurer, including federal and state health care programs, I am responsible for and agree to pay all amounts not paid for by my insurer(s), including applicable coinsurance and/or deductible amounts. If my insurer pays me directly for services rendered by CareneticPT, I will provide CareneticPT with copies of the insurer’s “Explanation of Benefits” and forward all payments received from my insurer to CareneticPT immediately upon receipt.

By signing below, I agree that all of the information that I have provided above is true and accurate to the best of my knowledge, that I have read and understand this form and that all of my questions have been asked and answered. I have been provided a copy of the CareneticPT “Patient Rights and Responsibilities” and acknowledge I have the responsibility to be involved in my care. I am signing this consent form willingly and voluntarily.

Print First Name:*

Print Last Name:*

Patient/Legal Representative Signature:*

Date:*

MM slash DD slash YYYY

For MINORS:

Patient Parent/Guardian Print Name:*

Patient Parent/Guardian Signature:*

Date:*

MM slash DD slash YYYY

*For Guardians and Legal Representatives, please provide supporting documents that proves you are the patient’s guardian/Legal Representative.

Front Desk Representative Name:

Date:*

MM slash DD slash YYYY

Name

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

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