Register Prior to Your Appointment

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The following form is available for you to fill out on your computer and print. You can then sign it and bring it with you to your appointment. You cannot save this file to your computer.

Registration Form.pdf

Patient Registration

Thank you for filling out the patient registration information prior to your appointment.

For NEW PATIENTS or if you have not been seen in the last 12 months: Please fill out the form below or the attached .PDF.

FOR RETURNING PATIENTS Click Here and fill out the form.

This form will take approximately 10 minutes to complete.
Today's Date
Patients Legal First Name
Patients Legal Last Name
Maiden Name
Birthdate
Age
Permanent Address
City
State
Zip
Email Address
Gender	Male Female
Marital Status	Single Married Separated Divorced Widowed
Home Phone
Work Phone
Cell Phone
Preferred Contact	Home Work Cell
Parent(s) or Spouse Name
Parent(s) or Spouse Work #
Parent(s) or Spouse Cell #
Nature of Visit	Cosmetic Medical Work Related Auto Injury
If work related, have you contacted your employer?	Yes No
Date of Injury
Primary Concerns
Date of Onset
If patient is under age 18, list responsible party
Relationship
Patient or Responsible party employer
Work	Full Time Part Time
Employment Address
City
State
Zip
Work Phone #
Job Description


(Insurance Card & Photo ID Must Accompany Appointment)
Name of Primary Insurance
Insurance Co. Address
City
State
Zip
Insurance Co. Phone #
Group #
Policy ID or Claim #
Policy Holder Name
Co-Pay Amount
Policy Holder's SS#
Policy Holder D.O.B
Case Worker/Adjuster
Phone #
Name of Additional Insurance
Insurance Co. Address
City
State
Zip
Insurance Co. Phone #
Group #
Policy ID or Claim #
Policy Holder Name
Co-Pay Amount
Policy Holder's SS#
Policy Holder D.O.B
Case Worker/Adjuster
Phone #


Emergency Contact: (Please List Friend or Relative Not Living with You
First Name
Last Name
Phone #
Relationship to Patient


Referred By	Dr. Self Yellow Pages Internet Friend or Relative Attorney Name Other
If Doctor, Name Please
Is this your primary doctor?	Yes No
List Primary Dr
Clinic Name
Address
City
State
Zip
Phone #


Contact Permissions For your privacy, please complete the following. Please list anyone with whom we have permission to speak with regarding your visit(s)/care with us via phone, answering machine, voicemail, email or in person:
First Name
Last Name
Relationship
First Name
Last Name
Relationship
First Name
Last Name
Relationship
First Name
Last Name
Relationship
May we contact you via Email?	Yes No
Would you like to be on our mailing list?	Yes No
If Yes, would you prefer to receive it by:	U.S. mail Email


You may change and/or revoke these permissions at any time by submitting a request in writing to: Attn Privacy Officer Midsota Plastic Surgeons PA 3701 12th Street N, Suite 100 St. Cloud, MN 56303
Patient Name (Please Print)
Signature
Date*
Patient Representative
If signed by patient representative, state authority to act on behalf of patent
I,
attempted to obtain patient's acknowledgment of receipt of the Notice of Privacy Practices, but was unable to do so.
Reason acknowledgement was not obtained
Signature*
Dept*
Date*
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