Patient Registration Form Template In MS Word

The patient registration form template is word template for register and record the new patient information. This template is almost identical with earlier form template, only this one supposed for printing purpose. Like its early version, it can be used for clinics, small hospital, and healthcare.

TEMPLATE OUTLINE

There are some elements in patient registration form template:

Patient Registration Form Template Header

Enter the clinic or hospital name here. Below the big header, there are fields for Form Date and PCP ID field. PCP ID may be served as primary key. Or you can add form number or ID field as primary key.

patient registration form sample

Patient Information

The tables about recording the patient information. The fields are:

  • Patient Last, First, and Middle Name
  • Patient Title: for calling: Mr., Mrs., Miss, or Ms.
  • Marital Status: Single, Married, Divorced, Separated, or Widowed.
  • Legal Name: fill if the patient ever changed their name or using other name.
  • Birth Date
  • Age
  • Gender
  • Addresses fields: Street Address, PO box number, City, State, and ZIP Code
  • Social Security Number: outside of US, you can enter the patient identification ID.
  • Home or Cell Phone Numbers
  • Occupation
  • Employer name and Phone
  • Referral: how do you referred or find the clinic/hospital. If you select Doctor or Other, include their name or their relation to you.
  • Other family member: enter other patients related with current patient.
patient registration form doc

Financial and Insurance Information

This is the tables for who will pay the medical bill and insurance setup. The fields are:

  • Responsible person for the bill: Name, Birth Date, Address, and Phone Number
  • Is responsible person is patient too in current clinic or hospital?
  • Responsible person job field: Occupation, Employer Name, Address, and Phone
  • Is the patient Covered by Insurance?
  • Insurances: enter the Insurance Company name in your country or places, before printing or given to the patients
patient registration form pdf

Below one is about the insurance subscriber information, which come in 2 insurance companies, one is primary while the other one is secondary. The fields are all same, except the secondary has no Co-Payment field:

  • Subscriber Name, SSN, birth date
  • Subscriber insurance group, policy, and co-payment
  • Patient relationship to Subscriber
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patient registration forms for a medical office

In Case of Emergency

Where to enter who to be called or contacted if something happened to patient. The fields are:

  • Name
  • Relationship with patient
  • Home and Work Phone
patient registration form template pdf

Patient Registration Form Template Signing Agreement

It has fields for Patient’s sign (or Guardian if the patient still underage or disabled) and Date of signing. By signing this, the patient has been agreed with clinic/hospital terms.

HOW TO USE

To use patient registration forms for a medical office, first edit or replace the placeholder text. This placeholder text mainly the information for choices, such as Insurance Company name in Insurance Information section. You can change the header with the clinic/hospital header including logo, name, and contact details.

Next, you can change the font formatting style such as font type, size, or color. You can add watermark by going to Design tab > Watermark > Custom Watermark. Then navigate to the pictures location or create one.

This template is not using macros for form, unlike the previous one. Patient registration form doc is simply for printing and manual writing purpose. The radio button or check boxes in this patient registration form template is mainly pictures or symbol instead and not clickable.

You can turn this into digital use by using Developer tab by going to File > Options. On appeared window, choose Customized Ribbons, and tick the Developer tab before click OK. Secondly, you can convert it as patient registration form pdf. Then, using Adobe Acrobat or other application to edit the patient registration form template pdf to fill the form.

CONCLUSION

You can use this patient registration form sample right ahead or use it as the sample for your own template. You can add more details, such as patient health history or disabilities.

The patient registration form template can be downloaded after you click: