Walk In Clinic Preregistration

Patient Information

First Name Middle Initial Last Name

Date of Birth

Day

Month

Year

Sex
Race Primary Language

Address

Street Address Line 1 Street Address Line 2 City State

Contact Information

Phone Number Email

Employment Information

Is the patient currently employed?
If yes, employer name If yes, employer address If yes, employer phone number

Visit Information

Reason for visit Primary Physician Last Name

Next of Kin Information

First Name Middle Initial Last Name

Address

Street Address Line 1 Street Address Line 2 City State

Contact Information

Phone Number Work Number Email Relationship to Patient

Emergency Contact

First Name Middle Initial Last Name

Address

Street Address Line 1 Street Address Line 2 City State

Contact Information

Phone Number Work Number Relationship to Patient

Insurance Information

Do you currently have insurance?
Insurance Company Name Policy Number Group Number Policy Holder First Name Policy Holder Last Name

Policy Holder Date of Birth

Day

Month

Year

Responsible Party Information

Is the responsible party the same as the patient?
Is there another responsible party?
If yes, please provide information on the responsible party

Other Information

Are you a spouse or dependent of a Bothwell Regional Health Center employee?
If yes, please provide employee's name.

Please bring any paperwork or order from your physician, insurance card, photo ID and payment.