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New Patient Registration

Complete before your first visit · Fields marked * are required

Patient Information

First Name*

Middle Name

Last Name*

Date of Birth*

Sex at Birth*

Preferred Pronouns

Social Security Number (last 4)

Marital Status

Contact Information

Home Address*

City*

State*

ZIP Code*

Phone (Primary)*

Phone (Secondary)

Email Address*

Preferred Contact Method

Emergency Contact

Emergency Contact Name*

Relationship*

Emergency Contact Phone*

Insurance Information

Primary Insurance Carrier

Member ID / Policy Number

Group Number

Insurance Phone Number

Policy Holder Name

Policy Holder Date of Birth

Relationship to Policy Holder

Primary Care & Referral

Current Primary Care Provider

How did you hear about us?

Consent to Treat

I authorize Roth Family Medicine & Mental Health to provide medical treatment and services. I understand that I am responsible for all charges not covered by my insurance. I authorize the release of medical information necessary for insurance billing purposes.

I have read and agree to the above consent to treat. *

Patient / Guardian Signature (type full name)*

Date*