Registration Form

Appointment Date *

Last Name of Patient (include Jr., II, III, etc., if applicable) *

First Name of Patient *

M.I.

Date of Birth *

*

Yes, Patient is a Minor

No, Patient is NOT A Minor

Social Security # (last 4 digits) *

Name of School Patient is Attending *

Any patient under the age of 18 must be accompanied by a parent or appointed guardian for ALL appointments.

Sex assigned at birth: *

Male

Female

Unknown

Gender Identity:

Male

Female

Transgender Female (Male to Female)

Transgender Male (Female to Male)

Genderqueer (neither exclusively male/female)

Choose not to disclose

Preferred Pronoun

He/His

She/Her

OtherOther

Height *

Weight *

Home Phone (Home or Cell Required)

Cell Phone

Work Phone

Preferred method for appointment reminders: *

Text

Voice Message

Can the office communicate via text? *

Yes

No

Email: Can we email you unencrypted? (If yes, please provide an email address):

Billing Statements *

I wish to receive paper statements by mail

I wish to go paperless, my email is listed.

Address

City

State/Province

Zip/Postal

Occupation *

Employer Name

Marital Status *

Spouse's Name

Spouse's Date of Birth

Spouse's Social Security # (last 4 digits)

Spouse's Place of Employment

Personal Insurance Carrier's Name

Subscriber/Member ID #

Group #

Policy Holder Name/Relationship to Patient

Parent/Guardian #1

Last Name (include Jr., II, III, etc., if applicable) *

First Name *

M.I.

Address *

Address

City

State/Province

Zip/Postal

Home Phone #

Cell Phone #

Email

Date of Birth *

Social Security # (last 4 digits)

Employer's Name

Employer's Phone #

Marital Status *

Spouse's Name

SECONDARY PARENT/GUARDIAN INFORMATION

Check to add Secondary Parent/Guardian information

Second Parent/Guardian Not Applicable or Deceased

Parent/Guardian #2

Last Name *

First Name *

M.I.

Address *

Address

City

State/Province

Zip/Postal

Home Phone #

Cell Phone #

Email

Date of Birth *

Social Security # (last 4 digits)

Employer's Name

Employer's Phone #

Marital Status *

Spouse's Name

In The Event The Parent/Guardian Is Not Present

Referral, Provider, and Pharmacy Information

Preferred Pharmacy (Name/Street/City)

Who referred you?

Primary Care Provider

Clinic Name

For statistical purposes only as required by the State of Wisconsin

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Refused to Report

Preferred Language *

English

Spanish

OtherOther

Check if you would prefer appointment reminders via text/voice in Spanish

Yes, send my reminders in Spanish

HIPAA and Emergency Contacts

Patient Authorization for use and disclosure of Protected Health Information (PHI) from the practice. Our office may contact you with appointment, billing and protected health information (PHI) through home, cell, or work number provided, and with your HIPAA approved contacts. It is your responsibility to inform the company of any changes. Please list contacts and check the box if they are HIPAA approved to receive PHI. One contact is required for Emergency use.

Name/Relationship (required)

Phone #

HIPAA Authorized Contact *

YES

Name/Relationship

Phone #

HIPAA Authorized Contact

YES

Name/Relationship

Phone #

HIPAA Authorized Contact

YES

Name/Relationship

Phone #

HIPAA Authorized Contact

YES

As part of the 21st Century Cures Act, the practice is enrolled in Carequality/Commonwell health information exchange. Upon query, authorized staff has access to necessary electronic health information. If you wish to opt out, please check the box and your records cannot be queried.

OPT OUT

I acknowledge that a copy of the Notice of Privacy Practices have been made available to me from Hand to Shoulder Center of Wisconsin and Woodland Surgery Center. Privacy Policy located in the link.

Yes

Click here to read the Privacy Policy

Patient/Representative Signature for Privacy Policy/HIPAA/Emergency Contacts

First name Digital Signature

Last name Digital Signature

If personal representative signed, describe relationship.

Date