Pre-Registration Pre-Registration Information Location:* ---Cambridge, MDEaston, MDPocomoke City, MDNorth Salisbury, MDSouth Salisbury, MDWest Ocean City, MD How did you hear about us?:* FamilyFriendRelativePrimary Care PhysicianTV CommercialEmployerDelmar billboardS Curve BillboardChincoteague billboardNew Church billboardWebsite SearchPrevious PatientOther What are you being seen for today?:* Personal Information Birthdate:* ---JanFebMarAprMayJunJulAugSepOctNovDec ---12345678910111213141516171819202122232425262728293031 ---191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016 Last Name:* First Name:* Middle Name: Suffix: Address:* City:* State:* Zip:* Email: Home Phone: Work Phone: Include any extension (if required.) Cell Phone: You must provide at least one of the above three phone numbers. Which is your preferred phone?: HomeWorkCell If we cannot get ahold of you, is it ok if we leave a voicemail?: YesNo Race:* American IndianAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteDeclined Ethnicity: Hispanic or LatinaNot HispanicDeclined Preferred Language EnglishSpanishIndianChineseKoreanOther Employer: Employer Contact Name (if work-related injury): Employer Contact # (if work-related injury): Primary Insurance Check this box if you are NOT the patient listed above and are filling this form out for another person. Primary Insurance: Lab Preference: LabCorpQuestNo Preference Name of Card Holder (Subscriber) (if different than patient): Sex (if different than patient): MaleFemale Policy Holder Address (if different than patient): Relationship To Card Holder: SelfSpouseChild Employer (if different than patient): Birthdate (if different than patient): ---JanFebMarAprMayJunJulAugSepOctNovDec ---12345678910111213141516171819202122232425262728293031 ---19151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Secondary Insurance Do you have secondary insurance? YesNo Secondary Insurance: Name of Card Holder (Subscriber) (if different than patient): Sex (if different than patient): MaleFemale Policy Holder Address (if different than patient): Relationship To Card Holder: SelfSpouseChild Employer (if different than patient): Birthdate (if different than patient): ---JanFebMarAprMayJunJulAugSepOctNovDec ---12345678910111213141516171819202122232425262728293031 ---19151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Workers Comp Workers Compensation Carrier (if work-related injury): Claim # (if work-related injury): WC Adjustor (if work-related injury): Adjustor Phone # (if work-related injury): Primary Care Physician Primary Care Physician (PCP): Note we will fax a copy of the encounter note from today’s visit to your PCP Location: Emergency Contact Emergency Contact:* Relationship: Home Phone: Cell Phone: Confidential Communication of Personal Health Information Please indicate individual (aside from yourself, if not minor), if any, authorized to speak with staff from Your Docs In regarding the patient’s evaluation, diagnosis, treatment and billing. Name: Relationship: Desired Time To Be Seen:* Please enter a time (i.e. 4:00 pm) that you would like to be seen. NOTE: The desired time is NOT guaranteed for a walk-in clinic and does not move you to the front of the line. Initials:* Enter your initials to represent your signature. Please enter these characters below:
