FAMILY PRACTICE HEALTH & WELLNESS MEDICAL GRP INC

KATHY CHRISTOPHER MD
803 COFFEE RD STE 11
MODESTO, CA. 95355

REGISTRATION FORM
(Please Print)

Todays date: PCP:      

PATIENT INFORMATION
Middle: Mr.
Patient’s last name:       First:       Marital status:
      Miss
Mrs. Ms. Single Mar Div Sep Wid
If not, what is your legal
Is this your legal name? (Former name): Birth date: Age: Sex:
name?
Yes No                         M F
Street address: Social Security no.: Home phone no.:
            (     )      
Mobile phone: City: State: ZIP Code:
                       
Occupation: Employer: Employer phone no.:
            (     )      
Chose office because/referred to office by (Please check
Dr.       Insurance plan Hospital
one box):
Family Friend Close to home/work Yellow Pages Other      
Other family members seen
     
here:
EMAIL ADDRESS

May we securely send appt reminders to you? Y_____ N_____

INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill: Birth date: Address (if different): Home phone no.:
                  (     )      
Is this person a patient
Yes No
here?
Occupation: Employer: Employer address: Employer phone no.:
                  (     )      
Is this patient covered by
Yes No
insurance?
Please indicate
primary insurance

Co-
Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.:
payment:
                              $      
Patient’s relationship to
Self Spouse Child Other      
subscriber:
Name of secondary insurance (if
Subscriber’s name: Group no.: Policy no.:
applicable):
                       
Patient’s relationship to subscriber: Self Spouse Child Other      
If you are interested in discussing any of our aesthetic procedures please indicate: Y_____ N______
 IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:
            (     )       (     )      

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I
also authorize Dr Kathy Christopher, FP Health & Wellness or insurance company to release any information required to process my
claims. I understand that I am financially responsible for any balance whether or not service is covered by insurance. In the event of
default, I agree to pay all cost of collection and reasonable attorney fees. I further agree that a photocopy of this agreement shall
be valid as the original.

Patient/Guardian signature Date

Thank you for your patronage