Patient Registration Form Please fill out form completely. Location Mercy Family Care Roscommon Patient Information Name:   (Last, First, Middle) Sex === Choose One === Male Female Birth Date Age: Social Security #: Referring Physician: Address Address: City: State Zip Mailing Address Mailing Address if different (P.O. Box) City State Zip Area code-Telephone # Marital Status === Choose One === Single Married Widowed Divorced Employment Employer (Patient or Parent) Employer's Address Employer's City Employer's State Employer's Zip Employer's Telephone Emergency Contact Relative or Friend to notify in case of an emergency (not living at patient residence) Telephone: Relationship to patient Pharmacy Name of Pharmacy Pharmacy Location Pharmacy Telephone Retired? === Choose One === Yes No Retire Date: What employer did you retire from? IS YOUR VISIT THE RESULT OF: AN AUTO ACCIDENT? YES NO AN ACCIDENT AT WORK? YES NO Date of Accident: Medicare Patients Are you or your spouse still working and have coverage under the employer's health plan? YES NO Are you entitled to Medicare due to a disability? YES NO Date of Disability: Primary Insurance Information Insurance Co. Name of Insurance Holder Relationship to Patient Birth Date Policy# or ID# Address Address if different from patient City State Zip Area code-Telephone# Employment Employer (Patient or Parent) Employer's Address Employer's City Employer's State Employer's Zip Employer's Telephone Secondary Insurance Information Insurance Co. Name of Insurance Holder Relationship to Patient Birth Date Policy# or ID# Address Address if different from patient City State Zip Area code-Telephone# Employment Employer (Patient or Parent) Employer's Address Employer's City Employer's State Employer's Zip Employer's Telephone If you are here with a child, we need to know your: Name Address Birth Date Relationship Social Security Number Day time Telephone Night Time Telephone Advanced Directive Do you have an Advanced Directive that outlines your healthcare wishes in the event you are unable to speak for yourself? === Choose One === Yes, please provide us with a copy for our records. No, but I would like more information. No, I am not interested. Your insurance will be billed for those services that are covered benefits. Payment for co-pays, deductibles and non-covered services is expected at the time of service. THANK YOU   By submitting this form, you indicate that you have completed all required fields with accurate information.