New Patient Registration Form
Please complete both sections 1 & 2 of the form. If you have any questions, please call us at 614-580-6917. Thank you.
Email address *
Patient's Legal Name: *
First, MI, Last
Your answer
Preferred Name: *
Your answer
Mobile Phone Number *
Your answer
Home Phone Number *
Your answer
Can we leave a message with the patient's mobile/home phone number? *
Yes, please sign me up to receive both email and text messaging appointment reminders/confirmations. *
Date of Birth: *
MM
/
DD
/
YYYY
Social Security Number: *
Your answer
Your Address: *
Street, Apt#, City, State, Zip
Your answer
Marital Status: *
Sex: *
Pharmacy Name and Phone Number: *
Your answer
Pharmacy Address: *
Street, City, State, Zip
Your answer
Name of Primary Insurance: *
Your answer
Patient is the Subscriber/Policy holder (Primary Insurance)? *
Name of Secondary Insurance: *
Your answer
Patient is the Subscriber/Policy holder (Secondary Insurance)? *
Primary Insurance Holder's Information: *
Policy Holder Name, Relationship to Patient, Date of Birth
Your answer
Emergency Contact Information: *
Name, Relationship to patient, Phone number
Your answer
Emergency Contact Information: *
Name, Relationship to patient, Phone number
Your answer
Release of Protected Health Information (PHI): Part 1
Per HIPAA guidelines you must give permission before any information can be released to anyone other than yourself or your legal guardian. Please list below the name(s) and relationship of any family/friends who may have access to your PHI on record at our office. This includes prescriptions refills, appointment times, diagnosis, office chart notes, and billing information.

If someone other than yourself contacts our office, and are not listed below, we will not release any information.

Please enter into the name and relationship to patient in the field below.
Release of Protected Health Information (PHI): Part 2 *
Name and Relationship to patient
Your answer
Release of Protected Health Information (PHI): Part 3 *
Check all items of information that may be released to above person(s):
Required
Release of Protected Health Information (PHI): Part 2 (Optional)
Name and Relationship to patient
Your answer
Release of Protected Health Information (PHI): Part 3 (Optional)
Check all items of information that may be released to above person(s):
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND OFFICE POLICIES: PART 1 *
I hereby acknowledge that I have been offered Emerald Psychiatry & TMS Center’s Notice of Privacy Practices and Office Policies.
Required
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND OFFICE POLICIES: PART 2 *
I hereby acknowledge that I have been offered Emerald Psychiatry & TMS Center’s Notice of Privacy Practices and Office Policies. PLEASE ENTER YOUR LEGAL NAME BELOW.
Your answer
APPOINTMENT CANCELLATION NOTICE:
If it is necessary to cancel an appointment, please call our office at least 24 hours before your scheduled appointment date. If a 24-hour notice is not given, a cancellation fee will be applied to your account.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy